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UNDERSTANDING CUSTOMER EXPECTATIONS OF 
COMMUNITY PHARMACY SERVICES 



By 
BARBARA F BRICE 



A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL 

OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT 

OF THE REQUIREMENTS FOR THE DEGREE OF 

DOCTOR OF PHILOSOPHY 

UNIVERSITY OF FLORIDA 

2000 















Copyright 2000 

by 
Barbara F. Brice 



This project is dedicated to Lee, Kate, and Rob. Their love supports and guides 
me always. 









ACKNOWLEDGMENTS 

This project could not have been completed without the support and guidance of 
my committee chairperson, Dr. Earlene Lipowski, who allowed me the freedom to explore 
and to choose a research method that best fit my and the project's needs. She fully 
supported my research journey and has given me a wonderful example to follow. Thanks 
also go to Dr. Sally Hutchinson, who applied her expertise and who kindly joined in and 
supported my exploration of grounded theory. I thank my other committee members, Dr. 
Carole Kimberlin and Dr. Richard Segal, for their time, help, and support. I thank Dr. 
Doug Ried for his time and input. I am especially thankful for my family, Lee, Kate, and 
Rob. Their love and support cannot be measured or described adequately enough. I 
thank my parents, Bob and Vera Flynn, for creating in me a need to read. I am very 
grateful for the support of my friends, Suzi Maue and Sabrina Scott. As fellow graduate 
students they understood my needs. I also thank all of my fellow pharmacy administration 
graduate students. I thank all of the folks at Mandarin Presbyterian Church. Their prayers 
and encouragement made a difference. I thank Delayne for all of the transcription work, 
and Debbie for being my phone buddy. I thank Bruce Allen for helping me draw the 
model. I thank Drs. Jerome Hallan, Nick Wilson, and Larry Jean, faculty members in the 
College of Health at the University of North Florida. It was their encouragement that led 



IV 



me to apply to the University of Florida. I thank Mel and Dennis, for allowing me access 
to their customers and their practices. I thank Leanne and Traci for allowing me to 
observe. I thank Broni for sharing her pharmacist tools. A capital thank you goes to all 
pharmacy customers. Clearly without them there would be no project. Finally, I am most 
grateful to God who led and continues to lead me on my path through life. 



TABLE OF CONTENTS 

^age 

ACKNOWLEDGMENTS iv 

ABSTRACT viii 

CHAPTERS 

1 INTRODUCTION 1 

Problem Statement 3 

Theoretical Perspective 4 

Research Purpose 7 

Significance for Pharmacy 7 

2 LITERATURE REVIEW 8 

Service Quality 11 

Expectations 23 

Summary of Literature Review 39 

3 METHODS 41 

Research Design 41 

Sample 42 

Data Collection and Recording 47 

Data Analysis 49 

Scientific Rigor 52 

4 FINDINGS: A MODEL OF PHARMACIST INTERCEDING 55 

Customer Needs: The Basic Social Problem 56 

Antecedent Conditions for Pharmacist Interceding 64 

Summary 68 



VI 












5 PHARMACIST INTERCEDING 69 

Assessing 69 

Acting 70 

Conditions Influencing Pharmacist Interceding 75 

Summary 81 

6 THE CONSEQUENCES OF PHARMACIST INTERCEDING 82 

Professional Relationships 82 

Personal Relationships 83 

Cases 83 

7 SUMMARY AND RECOMMENDATIONS 94 

Summary 94 

Model of Pharmacist Interceding 95 

Relationship of the Model of Pharmacist 

Interceding to Other Research 97 

Limitations 98 

Recommendations for Pharmacy Practice 99 

Recommendations for Future Research 99 

REFERENCES 101 

APPENDICES 

A INITIAL INTERVIEW GUIDE 106 

B REVISED INTERVIEW GUIDE 107 

C DEMOGRAPHIC AND PHARMACY EXPERIENCE QUESTIONS 109 

BIOGRAPHICAL SKETCH 110 



vu 



Abstract of Dissertation Presented to the Graduate School 
of the University of Florida in Partial Fulfillment of the 
Requirements for the Degree of Doctor of Philosophy 

UNDERSTANDING CUSTOMER EXPECTATIONS OF 
COMMUNITY PHARMACY SERVICES 

By 

Barbara F. Brice 

May 2000 

Chairperson: Earlene Lipowski 

Major Department: Pharmacy Health Care Administration 

Customers of health care have often been ignored when assessing the quality of the 

medical care that they receive. Historically, customers simply followed doctor's orders 

and did not participate in assessing the quality of the care that they received. As the focus 

of the health care system in general and pharmacy in particular evolves, both are making 

strides toward including the customers' perspective when assessing quality. However, 

current efforts to include the pharmacy customer in quality assessment seem to lack a 

theoretical underpinning. Therefore the purpose of this grounded theory research was to 

generate a substantive theory that explains customer expectations of community pharmacy 

services, as those expectations may be a foundation on which to measure service quality. 

A convenience sample of 27 community pharmacy customers was interviewed. In 

addition, observations of the pharmacist-customer interaction took place in four 

viii 



community pharmacies. Data were collected and analyzed using the grounded theory 
method. Findings show that pharmacy customers participate in a medication use system 
that they do not fully understand. This misunderstanding creates needs, the basic social 
problem, for those customers. Included are needs for information, needs for a problem 
solver, and needs for reassurance. This set of needs is addressed by the pharmacist acting 
on the customer's behalf in the medication use system. The pharmacist's acting, called 
interceding, is the basic social process that occurs in response to the customers' needs. 
However, two conditions, need identification and pharmacist expertise, must precede 
pharmacist interceding. Because interceding is a process, two phases occur: assessing and 
acting. Also, several conditions influence interceding. They include pharmacy 
environment, time, social structural variables, and personal characteristics. The 
consequence of pharmacist interceding is the formation of a relationship between 
pharmacist and customer. The proposed Model of Pharmacist Interceding illustrates the 
connection between customer needs, pharmacist interceding, and the pharmacist-customer 
relationship. Understanding the Model of Pharmacist Interceding provides pharmacists 
with new insight into the needs created by the medication use system for their customers. 
It shows pharmacists that customers expect their intercession in this system, and it 
demonstrates that a relationship is the consequence of pharmacist interceding. 









IX 













CHAPTER 1 




INTRODUCTION 



This is a study of customer expectations of community pharmacy services. It is a 
study that seeks to create a theoretical understanding of customer expectations that is not 
yet found in the academic literature. The following paragraphs outline the importance of 
including the customer's perspective in assessing health care, and the current study of 
customer expectations in an effort to support the importance of understanding those 
expectations. 

Customers of health care have often been ignored when assessing the quality of the 
medical care that they receive (Davies and Ware, 1988). In fact, during the 1980s the 
health care community focused on containing skyrocketing costs. Little attention was paid 
to anyone's assessment of quality of care. However, the tide has turned and health care 
customers, providers, and payers seem to have refocused their interests toward the quality 
of the health care that they receive, provide, and pay for. This renewed interest in quality 
leads us to an examination of the roles that customers, providers, and payers can and 
should take in assessing and defining quality. 

Historically, customers of health care played a passive role in assessing the quality 
of their care. They simply followed the "doctor's orders." Patients did not participate in 
assessing the quality of the care that they received. In fact, there was an argument against 

1 



customers evaluating their own health care. The validity of customer ratings of health 
care was questioned on four points: (1) the data provided by customers reveals more 
about the customer than the quality of care; (2) customers are able to tell how much was 
done, but not how well it was done; (3) customers' and physicians' judgements regarding 
quality are different; and (4) customers' ratings of quality just reflect whether their 
provider was nice (Davies and Ware, 1988). However, in a review, Davies and Ware 
(1988) consider the evidence both for and against customer participation in quality 
assessments of care. The evidence collected in their review suggests that data from health 
care customers can be useful in assessing the quality of medical care. For example, they 
found that for common problems customers can distinguish between good and less than 
good technical aspects of care. Also, customers' perceptions of quality affect their choice 
of health care provider. Finally, they found that customers are the best source of data on 
the interpersonal aspects of care (Davies and Ware, 1988). 

Kaplan and Ware (1995) also discuss the patient's role in health care quality 
assessment. They suggest that there are five reasons to include patients in the evaluation 
of their care. First, they suggest that patients' evaluations are the most practical source of 
information. Second, patient or customer satisfaction with services has been shown to 
affect both the patient-physician relationship and the patient's health status. Dissatisfied 
patients change physicians, change health plans, sue their providers, do not follow 
treatment recommendations, and avoid medical care altogether. Third, they indicate that 
research has shown a link between clinical measures of health and patient-reported 
outcomes. Fourth, they suggest that there is evidence that patients want to expand their 



role in their health care, and that they want to receive more information from their 
providers. Finally, Kaplan and Ware suggest that if patients are not satisfied with their 
care, they may turn to alternative therapies and/or therapists. 

As the health care system and its focus on quality evolves, it is apparent that the 
customers' role in assessing their quality of care has become increasingly important. For 
example, the American Medical Association Council on Medical Service includes the 
patient's informed cooperation and participation in decision making as an element of 
quality medical care (Council on Medical Service, 1986). Also, Christensen and Penna 
(1995) suggest that health care quality includes patients' expectations. In addition, 
Holdford (1999) examined the relative importance of functional and technical quality on 
patient perceptions of pharmaceutical service quality. Finally, Nau (2000) investigated 
patients' perceptions of the benefits of participating in pharmaceutical care services. 

Problem Statement 

While health care in general and pharmacy in particular are making strides toward 
including the customer's perspective when assessing quality, the task is not complete. 
Current research efforts aimed at defining service quality and/or customer satisfaction 
have provided a complicated mix of results. However, one thread seems to weave 
through the research and may be a foundation on which to build measures of service 
quality and customer satisfaction. That thread is customer expectations. In other words, 
the customer expectations construct is repeatedly found in studies concerning service 






quality and customer satisfaction. Because of its seemingly foundational role, a clear 
theoretical understanding of the expectations construct may lead to more useful definitions 
of service quality and customer satisfaction. 

Research centering on customers' expectations may be found in many disciplines, 
including marketing and pharmacy. However, like service quality, no consensus has been 
reached on a theoretical definition of the expectations construct. Because the expectations 
construct has been a frequent topic of research, and because clarification of the construct 
is needed, the grounded theory method provides an effective way of examining customer 
expectations. Grounded theory will provide a better understanding of how customers 
think about their interactions with their pharmacist(s), and what those customers expect 
from the interactions. 

Theoretical Perspective 

Symbolic interactionism, the sociological roots for the grounded theory method, 
finds its foundation in the work of Herbert Blumer. Blumer (1969) originally coined the 
label, symbolic interactionism, as a way to describe a particular approach to the study of 
human conduct and group life. 

Blumer (1969) suggests that symbolic interactionism rests on three premises. The 
first is that humans act toward things or objects based on the meanings that the things 
have for them. These objects include everything that people find within their world, 
ranging from physical objects such as a football to guiding ideals such as honesty. The 



meanings of things to people are central in their own right and cannot be ignored when 
studying human behavior. Blumer (1969) suggests that to disregard the meanings of 
things in favor of factors declared to produce behavior is a serious neglect of the role of 
meaning in the formation of behavior. 

The second premise, according to Blumer (1969), is that the meaning of things 
derives or arises from the social interaction of people. Therefore, meanings are social 
products. They are created through the defining activities of people as they interact. 

Finally, Blumer (1969) states that meanings are handled and modified by an 
interpretive process that is used by individuals as they deal with the things that they 
encounter. There are two steps in the interpretive process. First, through a process of 
self-communication, an individual points out to himself the things that have meaning. 
Second, through this process of self-communication, interpretation becomes a matter of 
handling meanings. The individual acts to select, check, suspend, regroup, and transform 
meaning based on the situation. Therefore, interpretation is a formative process in which 
meaning is used and revised as necessary for guiding and forming action. Meanings 
perform a part in action through the process of self-interaction. 

Blumer (1969) suggests that as a human society, people are engaged in living 
through symbolic interactionism. Living is a process of ongoing activity in which humans 
develop lines of action for the many situations they encounter. People are involved in an 
immense process of social interaction to which they must fit their developing actions. 
Through the process of social interaction, individuals indicate to others what to do, and, in 
turn, interpret the indications made by others. Humans live in a world of objects or things, 









and they are guided in action and orientation by the meaning of those things. Meanings of 
those things, including themselves, are formed, sustained, weakened, and transformed 
through social interaction. Because people cluster in different groups, have different 
occupations, and belong to a myriad of associations, they approach each other differently, 
live in different worlds, and are guided by different sets of meanings. 

Symbolic interactionism provides the foundation for the grounded theory method, 
and as such guides the research questions, the interview questions, the data collection 
strategies, and the data analysis techniques of the method. The grounded theorist searches 
for the social processes present in human interaction. Grounded theory is useful in studies 
where little is known about a particular subject or where much is known but clarification is 
needed. Because grounded theory uses an inductive, from the ground up approach, a new 
understanding of behavior may emerge, and the generated theory will be inherently 
relevant to the world from which it emerges (Hutchinson, 1993). 

In this study, the interaction between community pharmacy customers and their 
pharmacist(s) was investigated using the grounded theory method. Grounded theory 
research endeavors to understand the common issues facing the group of people under 
study. A group's common experience leads to shared meaning and behaviors which in turn 
leads to a specific social psychological problem. While this basic social problem is shared, 
group members may not be able to articulate it. It is the job of the grounded theorist to 
uncover the problem. Therefore, pharmacy customers were interviewed and observed in 
order to identify and understand the basic social problem they face, and the basic social 
process used to address that problem. The data collected from the interviews and 



observations provides a better understanding of how pharmacy customers interact with 
and assign meanings to their interactions with their pharmacist and the medication use 
system. 

Research Purpose 

The purpose of this study was to build a substantive theory that explains customer 
expectations of community pharmacy services. 

Research Questions 

1 . What is the basic social problem faced by community pharmacy customers? 

2. What basic social process is used to address this problem? 

Significance for Pharmacy 

Findings from this study will be useful on several fronts. First, the grounded 
theory will provide pharmacy researchers with a common starting point for future 
expectations research. Second, because the theory is specifically focused on the 
expectations of community pharmacy customers, community pharmacists will be able to 
use the theory as an aide in examining their own practices. Finally, understanding 
customer expectations may enable pharmacy educators to develop better tools for telling 
pharmacy customers about the services their pharmacist may provide. 



CHAPTER 2 
LITERATURE REVIEW 



Like all professions, the practice of pharmacy continually evolves. As the 
profession changes so do the interactions between pharmacist and customer, and a change 
in the way that pharmacists and customers interact may affect customer expectations. 
Four events seem to be shaping the current practice of community pharmacy, and 
therefore customer expectations. Those events are: (1) the arrival of pharmaceutical care, 
(2) the Omnibus Budget Reconciliation Act of 1990, (3) managed care, and (4) the shift 
toward an emphasis on quality of care. Each is discussed in turn. 

In their 1989 article, Hepler and Strand suggest that pharmacy adopt 
pharmaceutical care as the philosophy of practice. They define pharmaceutical care as 
"the responsible provision of drug therapy for the purpose of achieving definite outcomes 
that improve a patient's quality of life" (p. 12). In order to accomplish this, the 
pharmacist must perform certain activities for the patient. These activities include: curing 
a disease, eliminating or reducing symptomatology, arresting or slowing the disease 
process, and preventing the disease or symptomatology. Pharmacy and its professional 
associations have embraced this concept as the philosophy of practice. In fact, 
pharmaceutical care has become its own industry. Some companies (e.g., Caremark) have 
been formed for the purpose of "teaching" pharmacists to perform pharmaceutical care. 



8 









Also, colleges of pharmacy have begun to revise their curricula so that newly graduated 
pharmacists are better prepared for the new practice style. 

The Omnibus Budget Reconciliation Act of 1 990 (OBRA) specified that 
pharmacists meet certain requirements each time a prescription is dispensed to a Medicaid 
patient. Those requirements involve: record keeping, prospective drug use review, and 
patient counseling. In turn, states have revised their pharmacy practice acts to mandate 
those services for all pharmacy patients. Complying with OBRA requirements caused 
some pharmacists to review and adjust their practice flow. For example, in order to better 
provide patient counseling, some pharmacists have rearranged their practice flow so that 
they are now the first and last contact for patients. In some pharmacies a separate 
counseling area has been constructed. 

The introduction of managed care into the pharmacy marketplace has also 
impacted the profession and its relationships with its customers. Participation in managed 
care contracts changes from year to year, leaving the pharmacy customer no choice but to 
change pharmacies. Formularies, put in place by managed care organizations to contain 
costs, may have an adverse effect on the pharmacist - customer relationship. Pharmacists 
must act as a kind of "enforcer" of the formulary. Physicians may begin to feel that the 
pharmacist only calls to question their choice of therapy, not to act as a therapy 
consultant. 

Finally, health care, including pharmacy, has begun to examine the quality of care 
provided. Several groups have an interest in pharmacy quality of care, each with their 
own agenda. Regulatory agencies are charged with public safety. These agencies work to 



10 
set a minimum level of performance for practitioners. Pharmacists must meet their 
requirements. Also, many organizations are developing report cards of pharmacist 
performance. These report cards measure performance on items such as generic 
substitution, significant drug interventions, and avoidance of therapeutic duplication 
(Pisano, Tocco, and Vogenberg, 1997). 

Examination of these four events shows a common thread running throughout. 
That is, each affects the pharmacist-customer relationship in some way. Pharmaceutical 
care works to increase the interaction between pharmacist and customer. Regulatory 
agencies specifically direct some of the interaction between pharmacist and customer. 
Managed care has perhaps interfered with the relationship by changing the pharmacist into 
an insurance benefits policeman. Finally, the advent of the service quality paradigm 
emphasizes the importance of the inclusion of the customer in care decisions. This 
examination leaves us with the question, what does the customer think? If these factors 
have affected the pharmacist-customer relationship, what is it that pharmacy customers 
expect, and why are those expectations important? 

The remainder of this chapter will explore those questions by presenting the 
theoretical literature which explores some of those factors. Specifically, the service 
quality and expectations literature will be presented as background supporting the need for 
a study of customer expectations of community pharmacy services. 


















1 1 



Service Quality 



Research in the area of service quality began in earnest in the mid 1980s when 
Parasuraman, Zeithaml, and Berry (PZB) presented their conceptualization of the service 
quality construct. Since that time the service quality literature has grown, with the 
predominant focus on the foundation work of Parasuraman, Zeithaml, and Berry. In the 
sections that follow, readers will find an overview of the work completed by service 
quality researchers. This overview is presented so that the reader may gain an 
understanding of the background work that supported the need for this study. 

Parasuraman. Zeithaml. and Berry 

The theoretical framework from which this study evolved was developed in 1985 
by PZB, and is part of a stream of research that this group of authors has continued to 
follow to date. PZB found that "quality is an elusive and indistinct construct" (p. 41) 
which is not easily described by customers. Therefore, PZB planned a research agenda to 
fill in the holes of service quality research. Their initial work included a review of the 
studies investigating service quality, a report of the results of an exploratory investigation 
of service quality in four businesses, development of a model of service quality, and 
suggestions for future research. 

PZB (1985) found that service quality had been the topic of few other research 
agendas. However, they did note that there seemed to be three underlying themes in the 
service quality literature: (1) customers may have a more difficult time evaluating service 



12 
rather than goods quality; (2) customer's perceptions about the quality of a service come 
from a comparison of their expectations with actual service performance; and (3) both the 
performance and outcome of the service encounter are part of the customer's quality 
evaluation. These underlying themes and the lack of a conceptual foundation for service 
quality led PZB to an exploratory qualitative study. 

So that they might lay the groundwork for a conceptual framework of service 
quality, PZB (1985) conducted an exploratory study of service quality. This study 
consisted of in-depth interviews with executives and focus group interviews with 
customers. Although the authors proposed a common set of service dimensions for all 
service providers, the service categories investigated in this research included retail 
banking, credit card, securities brokerage, and product repair and maintenance. 
Participating executives were selected from the customer relations, marketing, operations, 
and senior management departments of each firm. Three to four executives with titles 
such as president, director, and senior manger participated from each firm. A total of 
fourteen executives were interviewed about a broad range of service quality issues. 

Customers were interviewed in a series of twelve focus groups. Focus group 
participants were screened to ensure that they were users of the service in question. The 
groups were designed to maintain homogeneity and assure maximum participation. 
Questions for the focus groups covered such topics as descriptions of an ideal service, 
factors important in evaluating a quality service, and the role of price in service quality. 

The results of both the executive and the customer focus group interviews led PZB 
to the development of the Service Quality Model (SQM). The model is formed by a series 



13 
of gaps between perceptions (both management and customer) of service quality and 
actual delivery of the service. The gaps may be characterized as follows: 

GAP 1 : The marketing information gap is the difference between customer 

expectations of service and management's understanding of those 

expectations. 
GAP 2: This gap, the standards gap, is the difference between 

management's understanding of customer expectations of service 

and the service standards which they specify. That is, this gap is a 

function of management's knowledge and use of customer 

expectations of service. 
GAP 3 : The third gap is the difference between service performance 

specifications and the actual performance of service. This is 

referred to as the service performance gap. 
GAP 4: The communication gap is the difference between communications 

to customers about the service and the actual performance of the 

service. 
GAP 5: The final gap is a function of the previous four gaps. This gap is 

the difference between customer expectations of service and their 

perceptions of actual service. The authors define perceived service 

quality with this gap. 

. 



14 
Examination of the five gaps shows that customer expectations are an integral 
component of Gaps one, two, and five. It could also be argued, that while not explicitly 
stated, customer expectations are a component of Gaps three and four. That is, according 
to the model, service performance specifications from Gap three are built on customer 
expectations. Also, the communications made to customers, found in Gap four, may 
affect those customers' expectations. 

The customer focus group interviews also provided a set often categories by 
which service quality was evaluated. These categories were reliability, responsiveness, 
competence, access, courtesy, communication, credibility, security, tangibles, and 
understanding/knowing (PZB, 1985). The authors suggested, in this work, that 
development of a measure of service quality that encompassed these ten categories or 
dimensions was appropriate. Also, they concluded, work was needed in developing 
measurements of the gaps and the importance of each gap in determining quality. 
Research regarding the impact of past experience, word of mouth communication, and 
personal needs on expected service was necessary. Finally, the authors suggested that it 
might be useful to segment customers on the basis of their service quality expectations 



(PZB, 1985). 



Zeithaml, Berry, and Parasuraman (1988) continued the development of the 
Service Quality Model by identifying a set of factors which might affect the magnitude and 
direction of the first four gaps in the model. Once again the authors conducted an 
exploratory study. This time the first stage of the study consisted of in-depth interviews 
with three to four executives in each of four nationally recognized service firms. Interview 



15 
questions were open-ended, and covered a wide range of service quality issues. The 
second stage of the research was a comprehensive case study of a bank. Employees at 
every level were interviewed. The third stage of the research process was a systematic 
group interview with eleven senior managers of six national service organizations. The 
insights gained from the three stages of the exploratory study were combined to suggest 
the main theoretical constructs and variables associated with each of the four gaps in the 
SQM 

The marketing information gap was associated with marketing research 
orientation, upward communication, and levels of management. The standards gap was 
associated with management commitment to service quality, goal setting, task 
standardization, and perception of feasibility. The service performance gap was associated 
with teamwork, employee job fit, technology job fit, perceived control, supervisory 
control systems, role conflict, and role ambiguity. Finally, the communications gap was 
associated with horizontal communication, and propensity to overpromise. 

The authors suggested that the model be tested with a technique such as LISREL. 
Perceived service quality as measured by SERVQUAL (Gap 5) would be the unobservable 
dependent variable, and the remaining four gaps would be the unobservable independent 
variables. Other suggestions for future research included: (1) determining which of the 
gap(s) is/are critical in explaining the variation in service quality; and (2) determining the 
organizational factors that are responsible for the size of the four gaps. 

SERVQUAL, a multiple item scale, was developed by PZB (1988) in order to 
assess customer perceptions of service quality. The authors based the initial development 






16 
steps on their earlier work in service quality (PBZ, 1985). They began with a definition of 
service quality as the discrepancy between customers' expectations of a firm's service and 
customers' perceptions about the actual service. In their 1985 article PBZ identified ten 
dimensions of service quality. Those ten dimensions served as a starting point for item 
generation. A ninety-seven item instrument was developed and subjected to two stages of 
data collection. As a result of the two stages of data collection a twenty-two item, five 
dimension scale emerged. The dimensions included: tangibles, reliability, responsiveness, 
assurance and empathy. Tangibles are defined as the "physical facilities, equipment and 
appearance of personnel" (p. 22). Reliability is defined as the ability to execute the 
promised service accurately and dependably. Responsiveness is the "willingness to help 
customers and provide prompt service" (p. 22). Assurance requires knowledgeable and 
courteous employees with an ability to inspire trust and confidence. Finally, empathy is 
the "caring, individualized attention the firm provides its customers" (PBZ, 1988, p. 22). 
Total reliability for the scale approached .90 in the cases of the four tapped service firms. 
Convergent validity was assessed by comparing an overall measure of quality with 
SERVQUAL scores using a one-way ANOVA. The scale was found to have convergent 
validity. 

An empirical examination of the Extended Service Quality Model (ESQM) may be 
found in PBZ (1990). PBZ developed a list of propositions to be tested empirically. The 
first four propositions hypothesized the relationship between the size of the gaps and their 
related theoretical constructs (e.g., the size of the marketing information gap is negatively 
related to marketing research orientation). The fifth proposition hypothesized a 



17 
relationship between customer expectations and perceptions and the size of the first four 
gaps. The final proposition hypothesized that the SERVQUAL instrument is a valid 
measure of customers' overall evaluations of service quality. Some of the propositions 
were supported while others were not. 

The results regarding the fifth proposition were mixed. The first four gaps were 
found to be weakly associated with Gap 5 (service quality gap), and account for a 
negligible amount of the variation in Gap 5. None of the regression coefficients were 
statistically significant. These findings leave one to question whether service quality is not 
measured by a difference between expectations and perceptions of performance, or 
whether the constructs have not been adequately operationalized? 

The results of the study done by PBZ (1990) led the authors to suggest the 
following future research scenarios: (1) refine the scale for the contributing factors, (2) 
conduct in-depth research on each gap, (3) investigate different levels of analysis, (4) look 
at differences among companies, (5) identify other variables, and (6) develop alternative 
measures of the difference score constructs. 

PZB have themselves gone on to further research in the area of service quality. 
They have continued work in the development of the SERVQUAL instrument (PZB, 
1991, 1994a, 1994b) and have studied the role and use of expectations and their link to 
behavioral intentions (Zeithaml, Berry, and Parasuraman, 1991, 1996). That literature is 
presented in a later section of this chapter. 












18 
Swartz and Brown 

In their 1989 article Swartz and Brown explored the evaluation process for 
professional services. Both providers and customers of a professional service (primary 
health care) were covered in their analyses. Health care customers were surveyed by 
means of a telephone interview. Health care providers (i.e., physicians) were surveyed by 
means of a mail questionnaire. The focus of the survey instruments was the perceptions of 
both customers and physicians toward health care and primary health care providers. 
Participants were presented with a series of statements regarding physicians, health care, 
and the public's view of each. They were asked to indicate their level of agreement or 
disagreement using a five-point scale. 

Results indicated that for both customers and physicians, the assessment of quality 
is a function of both expectations and experiences. The authors used their results to 
construct a conceptual model for evaluating professional service quality. This model 
showed that a series of gaps were likely to occur when measuring service quality. Gap A 
was the difference between customer expectations and their actual experience. Gap B was 
the difference between customer expectations and physician perceptions of their patient's 
expectations. Gap C was the difference between customer experiences and provider 
perceptions of patient experience. Finally, Gap D was the difference between a physician's 
personal thoughts about the patient and what they perceive the patients' views to be. 






19 
Bolton and Drew 

Bolton and Drew (1991) conducted a study in which they investigated how 
customers' evaluations of service quality were affected by changes in service offerings. 
They performed a field experiment in which customers were repeatedly surveyed while a 
significant service change was implemented. The study focused on temporal changes in 
individual attitudes (i.e., evaluations of service quality). The authors outlined a general 
model of attitude as follows. Attitude about a service depends on one's prior attitude. 
This is modified by perceptions of current performance, prior expectations of 
performance, and the difference between expectations and perceptions. 

Results of the study, which involved telephone company customers, indicated that 
perceived improvement in telephone service had a positive effect on customer attitude. 
Also, customer perceptions of current performance seemed to have the biggest impact on 
satisfaction and attitude. As hypothesized, current attitudes were influenced by prior 
attitudes. Finally, the authors noted that individual ratings of the components of service 
quality were sensitive to the effects of a service change, but average ratings of service 
quality were stable and change slowly. 






Cronin and Taylor 

In their article, Cronin and Taylor (1992) suggested that the conceptualization and 
operationalization of service quality by the SERVQUAL instrument was not adequate. 
They contended that the marketing literature instead supports a simple performance based 
measure of service quality, customer expectations should not be included. Therefore, they 



20 
developed and tested the SERVPERF instrument. In addition, the authors examined the 
relationships between service quality, satisfaction, and purchase intentions. 

Results of their research suggested that quality should be conceptualized and 
measured as an attitude. In addition they contended that the SERVPERF scale explains 
more of the variation in service quality than does SERVQUAL. They believed that this is 
true because SERVQUAL is based on a satisfaction rather than attitude paradigm and the 
SERVQUAL model is not confirmed for all industry types. 

The seemingly contrariness (to PBZ) of this study points to need for additional 
study of the service quality and customer satisfaction constructs. In addition, even though 
the authors do not support the use of expectations in a measure of service quality, they do 
support expectations as an element of customer satisfaction. 

Boulding 

Boulding, Kalra, Staelin, and Zeithaml, (1993) developed a dynamic process of 
service quality. They propose a model of service quality that follows customers' formation 
and updating of perceptions of service quality. Also, the model delineates the effect of 
those perceptions on individual behavioral intention variables. The authors made two 
assumptions in the model: (1) a customer's current perceptions of service quality after 
receiving the service are a blend of their prior expectations of what "will", and what 
"should", happen and the actual delivered service; and (2) customers update their 
expectations whenever they receive information about the service firm. This implies that 
change and/or personally relevant experience may impact customer expectations. The 



21 
model was tested first in a laboratory study which involved multiple encounters within a 
hotel setting. The analyses of the first study suggest that (1) "will" and "should" 
expectations are different constructs; (2) "will" expectations positively affect and "should" 
expectations negatively affect customers' perceptions of service quality; and (3) there is a 
measurable effect of "will" and "should" expectations on behavioral intentions when the 
service is fixed. The second study involved a field study conducted in an educational 
institution. Results of the second study indicated once again a link between perceived 
quality and behavioral intentions. 

Spreng and Mackoy 

Spreng and Mackoy (1996) discussed the conceptual arguments separating service 
quality and customer satisfaction. Included in those arguments is the effect of customer 
expectations on measurements of service quality and customer satisfaction. This was 
accomplished by testing a model of service quality and satisfaction first developed by 
Oliver (1993). In this model Oliver suggested that service quality is a function of the 
comparison between ideals and perceptions of performance regarding quality dimensions. 
However, satisfaction is a function of the disconfirmation of predictive expectations 
surrounding both quality and non-quality dimensions. Also, perceived quality is an 
antecedent of satisfaction. Spreng and Mackoy contend that there are several limitations 
to the model. These include: (1) satisfaction is not related to disconfirmation of ideals, 
and (2) expectations do not influence perceptions of performance. 



22 
To test the model Spreng and Mackoy examined student assessment of an 
undergraduate advising office. Participants filled out a questionnaire prior to meeting with 
an advisor. This questionnaire asked about student's desires and expectations regarding 
ten attributes of advising. Students also completed a post-advising appointment 
instrument. Again all ten attributes were measured. The authors completed confirmatory 
factor analysis and structural equations modeling on the data collected by the surveys. 
Results indicated that service quality and satisfaction are two distinct constructs. 

Summary of the Service Quality Literature 

It is clear from this review that a real interest in service quality research exists. It 
is also clear that one thread appears in most of these models. That thread is customer 
expectations (PBZ, 1990; PZB, 1985, 1988; Swartz and Brown, 1989; Bolton and Drew, 
1991; Boulding et al., 1993; Spreng and Mackoy, 1996) In fact, in a review of the 
literature pertaining to service quality, Iacobucci, Ostrom, Braig, and Bezjian- Avery 
(1996) found that most models of service quality contain an expectations component. 
Therefore, it appears that there is support for further study of the expectations construct. 
The next section of this chapter provides a review of the literature as it directly relates to 
the expectations construct. 












23 
Expectations 

The expectations construct has a wide and varied past. It has been studied by 
many disciplines, including economics, behavioral decision theory, and marketing (Oliver 
and Winer, 1987). Because the theoretical framework that provoked the need for this 
study evolved within the marketing discipline, the initial focus of this review will be on 
expectations as studied within the marketing literature. This will be followed by a review 
of expectations as studied in the pharmacy literature. 

Expectations and Marketing 

In marketing, the expectations construct is described primarily in the 
satisfaction/dissatisfaction and service quality literature. This section will provide a 
general review of the construct as presented in those areas. 

One of the earliest definitions of expectation may be found in the work of 
Georgescu-Roegen (1958), who defined expectations as "the state of mind of a given 
individual with respect to an assertion, a coming event, or any other matter on which 
absolute knowledge does not necessarily exist" (p. 12). He suggested that expectation and 
motive are two distinct constructs. 

An exploration of the expectations construct continued with the work of Olson 
and Dover (1979). These authors criticized past work in disconfirmation of customer 
expectations. They suggested that the expectations construct had not been clearly tested 
or conceptualized. Therefore they presented a definition of expectations as pretrial beliefs 



24 
about a product. This allowed disconfirmation research to focus on: (1) the processes by 
which belief expectations were created; (2) the effects that product trial experience have 
on belief structures; and (3) the effects of pre and post trial beliefs on attitudes, intentions, 
and behavior. Their study was designed to demonstrate the usefulness of conceptualizing 
expectations as beliefs, and provide a stimulus for future research. 

In their study Olson and Dover (1979) first exposed the subjects in the 
experimental group to three ad-like communications from a coffee manufacturer. The 
subjects were then asked to complete and return a written survey. In the fourth and final 
exposure all subjects (control and experimental) participated in a taste test. The authors 
were successful in creating a pretrial belief, in the experimental group, that the coffee was 
not bitter. Results of the taste test showed that the experimental group was significantly 
different than the control group in assessing the bitterness of the coffee. The control 
group found the coffee to be more bitter than the experimental group both before and after 
the experimental manipulation. 

In his 1980 article, Oliver presented the case for the inclusion of the expectations 
construct in the study of customer satisfaction. He argued that data from studies of that 
time showed significant expectations effects when expectations were manipulated or 
measured prior to product exposure. He also provided a study of the relationships among 
expectations, disconfirmation, satisfaction, attitude, and purchase intention. In the study 
expectations were measured as "the perceived belief probabilities attributed to eight 
consequences of receiving the flu shot" (Oliver, 1980, p. 462). Results seemed to support 
that post-usage ratings of satisfaction were a function of expectations and disconfirmation. 



25 
Woodruff, Cadotte, and Jenkins (1983) provided readers with an alternative model 
to the confirmation/disconfirmation model of satisfaction. In their conceptual model 
expectations are replaced with experience-based norms. These experience based norms 
are the standard of comparison for a brand's performance. They base this "replacement" 
on the argument that to date expectation based disconfirmation measures had modest 
correlations with measurements of satisfaction. Also, they suggested that if one applied 
social equity theory, the basis for comparisons of a brand's performance became the 
degree of equity between the customer and their peers. Finally, they suggested that brand 
comparison levels be based on the perceived capabilities of several brands in a brand 
category. Therefore, satisfaction may be based on both standards and expectations. 
In 1991, Zeithaml, Berry, and Parasuraman (ZBP) examined the nature and 
determinants of customer expectations of service. The authors found that there is 
agreement, in the literature, that expectations serve as standards for future experiences. 
However, questions remain on other issues. For example, what is the specific nature of 
the expectation standard? Also, how many standards are used? Finally, what are the 
sources or antecedents of theses standards? 

In order to answer the above questions, ZBP conducted focus group interviews 
with customers. This exploratory research laid the groundwork for a conceptual model of 
customer expectations of service. Sixteen focus group interviews were held. These group 
interviews were divided into different segments as follows: (1) business customer and pure 
service; (2) business customer and product related service; (3) end customer and pure 
service; and (4) end customer and product related service. Four focus group interviews 



26 
were held with customers from each group. Two interviews were with experienced 
customers and two with inexperienced customers. The interviews were held in five cities, 
Atlanta, Chicago, Seattle, Rochester, and Dallas. Interviews were conducted by field 
research companies in those cities. The interviews were unstructured in manner and 
included broad open ended questions. 

The analyses of the focus groups results involved a three step process. First, the 
researchers conducting the groups met at the end of each interview to informally discuss 
their impressions of the interview and to identify any emerging themes. Second, themes 
identified by the first focus groups were also informally identified in later interviews. 
Finally, a formal content and interpretive analysis of written transcripts was conducted 
after all focus groups were completed. With these results the authors constructed a 
generic model of customer expectations of service, which serves as an addition to the 
Extended Service Quality Model. ZBP's generic model of customer expectations may be 
divided into four sections, the expected service component, antecedents of desired service, 
antecedents of both predicted and desired service, and antecedents of adequate service. 
Each of these is described below. 

The expected service component is comprised of three parts, expectations for 
desired levels of service, expectations for adequate levels of service, and a zone of 
tolerance between the two. Expectations for desired levels of service may be defined as 
the level of service that the customer hopes to receive. This is a blend of what the 
customer believes can and should be. Expectations for an adequate level of desired 
service may defined as the level of service the customer will accept. ZBP (1991) 



27 
hypothesized that a customer's expectations for an adequate level of service would be 
more variable than their expectations for desired levels of service. They based this 
hypothesis on the assumption that desires come from an accumulation of experiences, 
while adequate levels are a function of competition among other variables. 

The zone of tolerance is the difference between a customer's expectations for a 
desired level of service and their expectations for an adequate level of service. The 
authors found (from the focus group interviews) that changes in the zone of tolerance are 
more a function of expectations for adequate levels of service. Also, the zone of tolerance 
may vary for the five dimensions of service quality: reliability, responsiveness, assurance, 
empathy, and tangibles. 

Expectations for desired levels of service are defined as the level of service that the 
customer hopes to receive. Focus group interviews provided six antecedents for desired 
levels of service. The first, enduring service intensifies may be defined as "individual 
stable factors that lead the customer to a heightened sensitivity to service" (ZBP, 1991, p. 
15). One type of enduring service intensifier is derived service expectations. In this 
instance a customer's expectations are driven by another party. Another enduring service 
intensifier is a personal service philosophy. This is a customer's underlying attitude about 
the meaning of service. The second antecedent is personal needs. Personal needs are "the 
states or conditions essential to the physical or psychological well being of the customer" 
(ZBP, 1991, p. 15). 

Four of the antecedents of desired service were found to impact predicted service. 
Explicit service promises are statements which the service provider makes to its 



28 
customers. Implicit service promises are simply cues, which the service provider makes, 
which lead to an inference about what the service encounter will be like. Word of mouth 
communications were another antecedent of desired and predicted levels of service. Past 
experience with the service is the final antecedent of desired and predicted levels of 
service. 

ZBP (1991) found that customer's expectations for adequate levels of service have 
five antecedents. Those antecedents include transitory service intensifiers, perceived 
service alternatives, customer self-perceived service roles, situational factors, and 
predicted service. The first antecedent, transitory service intensifiers may be defined as 
"temporary individual factors that lead the customer to a heightened sensitivity to service" 
(p. 16). Perceived service alternatives are simply the customer's perceptions of the 
availability of a comparable service. That is, what is the competition? The third 
antecedent, customer self-perceived service role relates to the customer's involvement with 
the service. It is the degree to which the customer perceives they influence the service. 
At times a service provider cannot control the situation in which the service is provided. 
The customer believes that these situational factors, the fourth antecedent, are not the 
service provider's fault and they may accept a lower level of adequate service. Predicted 
service is the level of service that customers believe they are likely to receive. It is 
important to note that this definition of predicted service is synonymous with the definition 
of expectations found in the satisfaction/dissatisfaction literature. 

The development of these various levels of expectations for service led ZBP 
(1991) to revise the gap model first presented in PZB (1985). The fifth gap was revised to 



29 
include two components: (1) the perceived service superiority gap; and (2) the perceived 
service adequacy gap. The perceived service superiority gap is the difference between 
desired and perceived levels of service. The perceived service adequacy gap is the 
difference between adequate and perceived service. 

PZB continued their research in the area of service quality with their 1994 
Marketing Science Institute report. In this report the authors examined three issues: (1) 
incorporation of adequate and desired expectations of service into the SERVQUAL 
instrument; (2) assessment of alternative service quality measurement approaches; and (3) 
examination of the relationship between customers' behavioral intentions toward service 
providers and service quality. Of these three issues, the first two are relevant to this 
literature review. The final issue is beyond the scope of the planned research study. 

In order to test the incorporation of adequate and desired levels of service into the 
SERVQUAL instrument, PZB developed and tested three versions of a questionnaire. In 
the first, a three column format, separate ratings of desired, adequate, and predicted 
service were obtained from three identical side by side scales. In the second, a two 
column format, direct ratings of the service adequacy and service superiority gap were 
obtained from two identical side by side scales. The third version was a one column 
format. With the one column format direct measures of the service adequacy and service 
superiority gap were also obtained. However in this version the measures followed one 
another, similar to the original SERVQUAL instrument. The twenty-two attributes found 
in PZB's 1991 version of the SERVQUAL instrument could be found in all three versions. 
In addition to the section described above, each questionnaire contained two questions to 



30 
assess respondent ease and confidence in their answering the questions. Also, questions 
were included that measured perceptions of overall service quality and value, relative 
importance of the SERVQUAL dimensions, behavioral intentions, and demographics. 

The surveys were mailed to customers of a computer manufacturer, a retail chain, 
an auto insurer, and a life insurer. The sample for each company was randomly divided to 
receive one of the three versions of the instrument. The overall response rate was 25%. 
All three versions of the instrument exhibited high reliability, and showed evidence of 
good predictive, convergent, and discriminant validity. The third version of the scale (i.e., 
one-column format) showed the most predictive power. This was followed by the two 
then three column version of the instrument. Predictive validity was measured by the 
percentage of variation accounted for in the single item overall measure of service quality. 

Thus far this review has provide a description of the expectations construct as 
explained in the marketing literature. The next section will review the construct as 
presented in the pharmacy literature. 

Expectations and Pharmacy 

The study of expectations is not new to pharmacy research. However the study of 
expectations has not traditionally been framed as in the marketing literature. That is, the 
pharmacy research seems to be atheoretical in nature. Outlined below is an historical 
overview of the construct as it relates to the practice of pharmacy. 

Knapp, Knapp, and Edwards (1969) undertook a study to examine the 
occupational role perceptions of the pharmacist. The authors suggested that if the 



31 
pharmacist was to take on a professional role in health care, current role expectations 
would need to be modified. In their study the authors developed two scales to measure 
the perceived occupational roles of pharmacists. Study participants included pharmacists, 
physicians, and the general public. 

The first scale contained statements describing possible characteristics of a 
pharmacist. Study participants responded to this scale by first circling the one item which 
they least wanted the ideal pharmacist to say or do. Next the participants were asked to 
circle the item which corresponded to their ideal pharmacist. This continued until the 
respondent circled no further items. Next, using the identical nineteen item scale, 
participants were asked to circle the one statement most like the pharmacist of today and 
the one statement least like the pharmacist of today. The procedure was modified for 
pharmacist participants. This group was asked to predict how the other groups viewed 
the pharmacist. The second scale was a semantic differential scale with nineteen pairs of 
bipolar adjectives. All participants were asked to rate the occupational concepts of 
physician, pharmacist, technician, and professional on each of the seven point bipolar 
scales. 

Results from the first scale showed that for all subjects there was agreement as to 
the most preferred and least preferred pharmacist characteristics. Also, there were no 
statistically significant differences among any of the groups for latitudes of acceptance and 
non commitment in the description of the ideal pharmacist. However, physicians and the 
general public of a lower socio-economic status (SES) were statistically different than the 
remaining groups in their latitudes of rejection. That is, physicians and the general public 



32 
of the lower SES group had higher standards for pharmacists than did pharmacists 
themselves. When perceptions of the ideal were compared to perceptions of the actual 
pharmacist, pharmacists were found to not be doing those activities considered most 
acceptable. Results from pharmacist participants showed that they rated the public as 
being less particular than they actually were. The semantic differential scale showed that 
physicians were rated most favorably. This was followed by professional, pharmacist and 
then technician. 

In a 1973 study conducted by the Dichter Institute for the American 
Pharmaceutical Association (APhA), participants indicated that pharmacists were first a 
business person with primarily commercial motivations. Also, in their study the Dichter 
Institute found that the public was not aware of the services that pharmacists could 
provide. 

In their study, Norwood, Seibert, and Gagnon (1976) examined the attitudes of 
rural customers and physicians toward expanded occupational roles for pharmacists. They 
suggested that because drugstores were more evenly distributed (i.e., accessible) than 
physicians, dentists, or hospitals, the pharmacist may be an ideal candidate for an 
expanded role. In order to assess the acceptance of a broader role for pharmacists, 
physicians in a nine county area of northeast Iowa as well as customers of a participating 
pharmacist were asked to complete a questionnaire. The questionnaire contained "should" 
statements describing roles that pharmacists might take. The physician group provided a 
33% response rate while the customer group provided a 28% response rate. 



33 
In regards to statements about pharmacist consultations for drugs, poisons, and 
sickroom supplies, both customers and physicians viewed all pharmacist roles favorably. 
Both customers and physicians indicated that pharmacists should use a patient's records to 
detect drug-drug interactions and should advise patients on prescription and non- 
prescription medications. Of interest were the roles that customers indicated they would 
pay for. Customers (27.6%) indicated that they would be willing to pay for the availability 
of surgical and sick room supplies. Also, customers (14%) indicated that they would be 
willing to pay for information regarding emergent treatment of poisonings. 

Patients and physicians differed in their rankings of the pharmacist's role in 
preliminary diagnosis, screening, and treatment. Customers viewed these roles more 
favorably but were not strongly in favor of the pharmacist acting in these roles. Physicians 
viewed any role of the pharmacist as a general health information source negatively. 
Customers were neutral for this category. Finally, neither physician nor customers 
positively viewed pharmacists in the role of drug selection, dosing, or administration. 

DeSimone, Peterson, and Carlstedt (1977) gathered data regarding the interactions 
between pharmacists and their patients. The authors believed that patient initiated 
interactions with his or her pharmacist showed a level of need as well as an expectation 
that the pharmacist could fulfill that need. Sixteen pharmacists participated in the study 
which gathered the following information: (1) patient age, (2) patient gender, (3) whether 
the patient came to or called the pharmacy, (4) whether the question concerned a 
prescription or non-prescription drug, and (5) the question category. 









34 
Results showed that patients most often asked for a recommendation for a non- 
prescription product. The second most often asked question regarded the indications of a 
particular drug product. Third, patients asked questions about their prescription refills. In 
terms of the demographic information gathered, results showed that women asked almost 
twice as many questions as men. In terms of age, respondents in the twenty to twenty- 
nine year old category had the most frequent contact with their pharmacist, while those in 
the over sixty age category were next to last in terms of frequency. Most questions were 
asked in person, and more questions were asked about prescription than nonprescription 
medications. 

In their study Ludy, Gagnon, and Caiola (1977) wished to determine if patient's 
satisfaction with pharmacy services could be increased and drug misuse decreased if the 
patient received more individualized care. Seventy-five patients were randomly assigned 
to either a satellite or traditional pharmacy. These patients completed two questionnaires. 
The first consisted of attitudinal questions about the patient's satisfaction with services in 
general and the interaction with the pharmacist. In addition, the patient was asked to 
indicate which of a list of nineteen activities they expected the pharmacist to do and 
whether the pharmacist performed the activity with each prescription. At a later date 
sixty-eight of the original patients completed a second questionnaire in their home or at 
the hospital. This questionnaire contained three attitudinal questions regarding the 
patient's satisfaction with the drug therapy. Also included were open-ended questions 
regarding the patient's recall about information provided about the drug therapy. 



35 
A chi-square analysis of the results showed that there was a statistically significant 
difference in expectations regarding most activities between those assigned to the satellite 
and those assigned to the traditional pharmacy. Also, patients were significantly more 
satisfied with the satellite pharmacy. Finally, waiting time, satisfaction with hospital 
service in general, time spent with the pharmacist, and the total number of activities 
performed by the pharmacist during an interaction were all significantly correlated with 
satisfaction. 

In order to better understand demand for comprehensive pharmaceutical services, 
Banahan, Sharpe, and Smith (1980) studied customer expectations and use of those 
services in a rural area. Trained personnel interviewed a responsible adult in 603 
households in a three county area of Mississippi. The interview questions covered a wide 
range of health care topics, including: demographic characteristics; use of and attitude 
toward pharmacy services; current health status and behavior; and general satisfaction 
with current medical services, among others. 

Results showed that patients most often expected services related to medications 
and medication use (e.g., 65.9% expected counseling on side effects). While most of the 
results were reported as frequencies, the authors did note some differences among groups. 
For example, respondents that either strongly or somewhat strongly agreed that 
pharmacists should counsel on side effects were more likely (p<0.01) to report that the 
pharmacist did explain side effects. Also, respondents who expected their pharmacist to 
provide health information (other than on drugs) were more likely (p<0.01) to report 
asking those questions. 



36 
Mackowiak and Manasse (1984) completed a study comparing the expectations 
for ambulatory services in both office based and traditional pharmacies. The study site 
was a small Midwestern town in which both pharmacy types existed. The study used a 
posttest only and measured differences in expectations and satisfaction between the two 
practice types. The study questionnaire was designed to measure patient expectations of, 
and satisfaction with, sixteen pharmacy services. To measure expectations the items were 
labeled: "I expect the pharmacist", and the satisfaction items were labeled "Level of 
satisfaction with the way your pharmacist provides this service is". Researchers attained a 
62% response rate. The mean expectation score for all respondents and all services was 
3.98, and the average satisfaction score was 3.74. Of the sixteen activities, office practice 
customers reported significantly higher expectations scores for ten of the activities. 
Satisfaction scores were also significantly higher in nine of the sixteen activities. In 
addition to practice type differences, the authors found that frequency of pharmacist 
contact was significantly related to higher expectation and satisfaction scores. 

In their study, Sirdeshmukh, Pathak, Kucukarslan, Segal, Kier, and Aversa (1991) 
presented the results of an exploratory analysis of patient satisfaction/dissatisfaction and 
post exchange actions in the high blood pressure prescription market. The study examined 
the relationship of patient satisfaction with providers of treatment (e.g., pharmacists) and 
the drug product to the following variables: expectations and performance, perceptions of 
equity, overall perceived satisfaction, and responses to dissatisfaction. 

Four focus groups with an average often customers each were conducted in 
Florida and Ohio. Participants were elderly high blood pressure patients. The interview 









37 
was originally conducted using a matrix approach with a horizontal investigation of all 
variables with respect to each exchange partner. That is, participants were first asked 
questions about the physician followed by the pharmacist, manufacturer, and then the drug 
product. However, the format was changed when researchers found that participants 
tended to speak about their experiences and feelings based on the variable rather than the 
exchange partner. Therefore, the last three focus groups followed a vertical investigation 
of each variable across exchange partners. Written transcripts of each focus group were 
content analyzed to identify the key themes associated with each variable. With regard to 
the first variable, expectations and performance, the analysis showed that patients judged 
their providers in terms of performance without an explicit use of expectations. The 
authors suggested that this was a result of the patients' high involvement state. However, 
patients did rely on expectations in the judgement of the drug product's side effects. 
Therefore the authors concluded that patients have two sets of standards, one for persons 
(e.g., pharmacists) and the other for tangibles (e.g., drug product). 

In order to gain a better understanding of customer expectations toward 
pharmacist provided drug information (PPDI), Wiederholt and Rosowski (1996) examined 
pharmacy customers in three community pharmacies. The study was based on the 
following questions: (1) do customers have expectations of PPDI as a service? (2) what 
antecedents are associated with the formation of those expectations? and (3) are patient's 
age, gender, and/or delivery site related to the expectations of service? The authors based 
their work on the model created by ZBP (1991). However, because the authors chose the 
customer satisfaction/dissatisfaction paradigm as an underlying theme, they chose 



38 
predictive expectations as defined in the model to be their dependent variable. The 
independent variables included past experience with PPDI, implicit services associated 
with PPDI, word of mouth communications associated with PPDI, and explicit service 
promises associated with PPDI. Each of these are suggested antecedents found in ZBP 
(1991). 

A multi-attribute measure of expectations toward PPDI was developed by 
examining existing literature, and the recommendations for patient counseling made by the 
National Association of Boards of Pharmacy, the Wisconsin Board of Pharmacy, the 
American Society of Health System Pharmacists, and OBRA 1990. This resulted in a list 
of thirteen attributes that were measured with a five point scale labeled definitely do not 
expect to definitely expect. 

A factor analysis of the multi attribute expectation scale revealed that all items 
loaded onto one factor which explained 56.4% of the variance. Cronbach's alpha for the 
scale was 0.97. Also, the four antecedents of customer expectations became six factors, 
intra personal sources, extra personal sources, past experience 1 (recency, frequency, 
times), past experience 2 (duration, completeness), implicit service promises, and explicit 
service promises. When examining the effects of the antecedent variables on customer 
expectations, the authors found that explicit service promises and word of mouth 
communication were the only two variables with a significant association. Association 
between the other variables (age, gender, and site) and expectations varied from pharmacy 
to pharmacy. 






39 
Ranelli and Coward (1997) examined the relationship between place of residence 
of elderly patients and their expectations about communication with pharmacists. 
Interviews were completed with 200 respondents from each of two (urban and rural) 
residence groups. Interviews were completed using a forty-six item scale. The scale was 
comprised of mostly closed end and forced choice items. 

The authors hypothesized that three clusters of independent variables (personal 
characteristics, self-reported health measure, and experience with prescription drugs) 
would affect the expectations of the respondents. The dependent variable was older adult 
expectations about communication with a pharmacist. 

Results showed that the rural sample, in general, held higher expectations for 
pharmacists. Of the nine items in the expectation scale, there were significant differences 
on six of the items. Also, the rural elders had higher means on all nine items. However, 
there was no significant difference between rural and urban adults in the relative rankings 
of the nine items. The multivariate analysis of the independent variables showed that place 
of residence was a significant predictor of expectations in three of the four models 
specified. Only in the fourth fully specified model did place of residence become 
insignificant. 

Summary of Literature Review 

Marketing literature is replete with research involving the expectations construct. 
However, most of the early research involved the customer satisfaction/dissatisfaction 



40 
domain (Olson and Dover, 1979; Oliver, 1980; Woodruff, Cadotte, and Jenkins, 1983). 
PZB (1985, 1988) and PBZ (1990) were the first marketing researchers to begin a 
thorough examination of the expectations construct in terms of the service quality domain. 
While they have continued to work in this area, they have not continued to develop the 
expectations construct. That is, they have made propositions about the construct (ZBP, 
1991; PZB, 1994b) but have not continued to examine the construct. 

Pharmacy literature also shows an interest in the expectations construct. 
Expectations of pharmacist roles were examined by Knapp, Knapp and Edwards (1969) as 
well as Norwood, Seibert, and Gagnon (1976). DeSimone, Peterson, and Carlstedt 
(1977) studied patient initiated contact with their pharmacists. Patient initiated contact 
was considered an expectation that the pharmacist could respond to the contact. The 
relationship of expectations with customer satisfaction/dissatisfaction is also a focus of 
study (Ludy, Gagnon, and Caiola, 1977; Sirdeshmukh, et al., 1991; Wiederholt and 
Rosowski, 1996). However, none of these studies defined expectations in terms of a 
service quality framework. In fact, few of the pharmacy studies provide any conceptual 
definition of, or theoretical framework for, the construct and often show conflicting 
results. Therefore, this study is proposed to fill that gap. That is, the purpose of this 
study is to develop a substantive theory of customer expectations of community pharmacy 
services. 

Using the grounded theory approach pharmacy customers were interviewed and 
observed in an effort to understand their expectations for community pharmacy service. 
That approach is described in the following chapter. 



CHAPTER 3 
METHODS 



The purpose of this research was to build a substantive theory of customer 
expectations of community pharmacy services. In order to accomplish this goal, the 
grounded theory method was used. That method and the specifics relating to this research 
are described below. 

Research Design 

The grounded theory method was developed by sociologists Barney Glaser and 
Anselm Strauss in 1967, as a way of systematically generating theory from data. 
Grounded theory enables the researcher to understand just how individuals interact with, 
and subsequently view, their world. This method is useful in studies where little is known 
about a particular subject or where much is known but clarification is needed (Hutchinson, 
1993). 

In grounded theory, data are collected (e.g., through interviews), coded (i.e., taken 
apart), and analyzed (i.e., put back together) in a continuous process. As data are 
compared, concepts emerge and categories are formed. Continued study reveals 
relationships among the categories along with higher conceptual levels of categories. 



41 



42 
Hypotheses about the data are generated and a core variable of a theory emerges (Glaser 
and Strauss, 1967). A grounded theory is complete when the properties, conditions, 
strategies, and consequences of that variable are explicated and integrated. 

As was indicated in the previous chapter of this work, the expectations construct 
has been studied from many viewpoints, however, researchers have not yet reached a 
common understanding of the construct. Therefore, grounded theory provides a method 
for examining the expectations construct directly from the data. The result of this study, a 
substantive theory of customer expectations of community pharmacy services, provides a 
clear common starting point for future expectations research. 



Sample 



Choosing a sample for qualitative interviews does not always follow the same rules 
(e.g., random sampling) as choosing a sample of participants to complete a quantitative 
survey. In qualitative research sampling is often purposeful. That is, the sample of events, 
settings, or persons is chosen to provide information that is not readily available from 
other choices (Maxwell, 1996). Using a random sampling technique to draw a small 
sample may introduce chance variation. 

Purposeful sampling has four possible goals. The first is to achieve 
representativeness in the chosen sample. That is, the sample will be systematically chosen 
for typicality and relative homogeneity. This may provide confidence that any conclusions 
actually represent the members of the population from which the sample was drawn. A 



43 
second goal of purposeful sampling is to specifically examine cases that are critical for the 
theoretical framework underpinning the study. A third goal is to pick a sample that will 
enable the researcher to make comparisons of the reasons for differences between those 
sampled. A fourth goal of purposeful sampling is to sufficiently capture the population's 
heterogeneity, with the aim of representing the range of variation within that population 
(Maxwell, 1996). The initial sample for this study was purposively chosen from 
community pharmacy customers with a range of pharmacy experiences. 

In order to assess the range of pharmacy customers to be sampled, the pharmacy 
expectations literature was examined. Past studies of pharmacy customer expectations 
examined customer's gender (DeSimone, Peterson, and Carlstedt, 1977; Kucukarslan, 
1998), race (Kucukarslan, 1998), and age (DeSimone, Peterson, and Carlstedt, 1977; 
Mackowiak and Manasse, 1988; Norwood, Seibert, and Gagnon, 1976). Kucukarslan 
(1998) included an assessment of education level in her study of expectations. 
Kucukarslan (1998) and Ranelli and Coward (1997) examined whether customers had 
acute or chronic illnesses, and the average number of prescriptions purchased. Also 
included in past studies of customer expectations were type of pharmacy patronized 
(Ludy, Gagnon, and Caiola, 1977; Mackowiak and Manasse, 1984; Kucukarslan, 1998) 
and frequency of pharmacy contact (DeSimone, Peterson, and Carlstedt, 1977; 
Mackowiak and Manasse, 1984). Each person interviewed was asked about these 
characteristics and an effort was made to represent the range in variation of the 
characteristics. 









44 
Sample Recruitment 

The first seven participants in this study were recruited by contacting individuals 
suggested by friends and asking for their participation. Only current or past customers of 
community pharmacies were asked to participate. All seven persons contacted agreed to 
participate. 

Recruiting later in the research process began in two independently owned 
community pharmacies in Jacksonville, Florida. I visited the two pharmacies on separate 
occasions and spoke with various customers about the research project while they were 
waiting for their prescriptions. The pharmacists and staff at both stores had been briefed 
about the project and at times they introduced a possible volunteer to this researcher. 
However, none of the pharmacy customers that were approached volunteered. Therefore, 
I devised another recruiting technique. 

The revised technique involved two changes. The first was to add a fifteen dollar 
gift certificate to a local restaurant as a token of regard and appreciation for the 
participant's time. In addition, a small bag clipper was developed. This bag clipper listed 
the researcher's name and phone number, a brief description of the participant's 
involvement, three ways to volunteer for the interviews, and a mention of the gift 
certificate. Staff at both pharmacies were asked to attach one pink bag clipper to each 
pharmacy bag. The bag clippers were put into use for a two week period, resulting in a 
total of twenty-three volunteers. Fifteen of those volunteers completed interviews, and 
the remaining eight are available for future interviews. 



45 
In addition to the bag clippers, friends and interviewees were tapped for possible 
volunteers. Eight additional individuals volunteered for interviews. Five have completed 
interviews, and the remaining three are available for future interviews. 

Sample Description 

Twenty-seven individuals participated in interviews during the course of this 
research. Twenty-one (78%) of the participants were female, and six (22%) were male. 
In regard to age, eight (30%) were under the age of forty. Nine (33%) of the interviewees 
were between the ages of forty and fifty-nine, and ten (37%) were age sixty and above. 
Ages ranged from twenty-eight to eighty-seven years. The majority, twenty-four of 
twenty-seven (89%) of the participants were white. Two (7%) were African American 
and one (4%) was Hispanic. The sample group included two (7%) individuals who had a 
high school diploma, and seventeen (63%) individuals who had some college experience. 
Eight (30%) of the participants had at least a four year college degree. 

There was an attempt to interview pharmacy customers who would have a range 
of pharmacy related experience. To that end, three (1 1%) of the interviewees paid for 
their medications themselves. Twenty (74%) of the interviewees shared payment with 
another source (e.g., insurance), and three (11%) of the interviewees depended on an 
outside source to completely cover the cost of their medication. One (4%) individual 
shared payment responsibility on some medications, and on others another source (i.e., the 
military) paid the bill. With regard to the type of pharmacy patronized, five (19%) strictly 
shopped at chain pharmacies. Sixteen (59%) of the participants shopped at independent 



46 
pharmacies, and one (4%) patronized a clinic pharmacy. Four (15%) of the participants 
patronized both chain and independent stores, while one (4%) patronized both a chain and 
military pharmacy. Of those asked (n=18), twelve (67%) participants visited their 
pharmacy at least every two weeks. Two (11%) visited monthly, three (17%) quarterly, 
and one (6%) visited yearly. Participants estimated that their average medication use 
ranged from one-half to twenty-five prescriptions per month. Most (twenty-three or 85%) 
indicated that they had some sort of chronic medical condition. Finally, of those asked 
(n=18), six (33%) rated their health status as fair, six (33%) as good, and four (22%) as 
excellent. One (9%) participant rated her health as poor to fair, and one (9%) as fair to 
good. 

Theoretical Sampling 

Theoretical sampling is defined as "the process of data collection for generating 
theory whereby the analyst jointly collects, codes, and analyzes his data and decides what 
data to collect next and where to find them, in order to develop his theory as it emerges" 
(Glaser and Strauss, 1967, p. 45). Theoretical sampling allows the researcher to sample 
not with a preconceived notion, but with real, specific guidance from what is occurring in 
the research setting (Glaser, 1978). In this study, theoretical sampling was employed after 
the interview participants were chosen. Theoretical sampling of the interview transcripts 
and field notes allowed me to pursue and expand the codes emerging from the data. This 
in turn led to the discovery of the basic social problem and process which form the core 
for the developing theory. 



47 
Data Collection and Recording 

Data for this research were collected through a series of semi-structured interviews 
and observations. Interviews were conducted at a time and place designated by the 
interviewee, and lasted from forty-five minutes to an hour and a half. Each interview was 
tape recorded and subsequently transcribed into the Word Perfect computer software. 

Customer - pharmacist interactions were observed on five separate occasions, with 
observation times ranging from two and one-fourth hours to six hours. I sat or stood in an 
inconspicuous place in each of the four pharmacies. Twenty-three pages of field notes 
describing the pharmacy environment as well the customer - pharmacist interactions were 
recorded. Observations took place in two independent pharmacies, one chain pharmacy, 
and one grocery store pharmacy. 

In addition to the customer interviews described above, four community 
pharmacists were asked to record their thoughts regarding the process that they used in 
problem assessment. One pharmacist provided his notes to me. Another pharmacist was 
interviewed via the telephone and I reduced the conversation to writing. 

Interview Guide 

An initial interview guide for this study was developed using a four step process. 
First, a review of the literature was undertaken. Next, with the aide of the research 
objective, the literature, and suggestions from Patton (1980), I developed nine, multi-part 
expectations interview questions. Then, faculty members in the College of Pharmacy 



48 
reviewed and suggested improvements in the questions. Finally, a practice interview was 
completed with the aid of a University of Florida Anthropology graduate student. A 
discussion of possible interview improvements followed the close of the practice 
interview. Revisions were made, resulting in the final interview guide. The final form of 
the interview guide includes introductory remarks, nine, multi-part, open-ended questions 
and four biographical questions. Throughout the interviews, probes were used as 
necessary to clarify points and/or to further tap any emerging ideas. The final form of the 
initial interview guide may be found in Appendix A. 

After seven interviews were conducted the interview guide was revised in an effort 
to expand the range of responses from the interview participants. Transcripts from the 
first seven interviews and continued exploration of the grounded theory methods literature 
served as a guide to the expansion of the questions. A group of sixteen questions formed 
the basis for the revised interview guide. After development, two faculty members from 
the College of Pharmacy reviewed the questions as an additional check. No revisions 
were made after faculty review. The final form of the revised interview guide may be 
found in Appendix B. 

In addition to the questions specifically relating to the area of interest, interviewees 
were asked a series of questions (Appendix C) focusing on both demographic and 
pharmacy experience variables. The responses to these questions were used to describe 
and to assess the breadth of the sample. 



49 
Data Analysis 

In grounded theory, data are analyzed in a detailed systematic manner. All 
interviews were tape recorded, transcribed, and entered into the computer software 
program WordPerfect. In addition, the complete transcripts of the first seven interviews 
were then entered into the software program Atlas. ti for Windows 95 version 4. 1. This 
software program aids in the organization, and coding of qualitative data. After data 
entry, each sentence of the interview transcripts was examined and coded. Comparisons 
were made among the codes, sentences, and interviews. Categories emerged and a theory 
was developed. Throughout the process the focus was on organizing the ideas that 
emerged from the data, not the data itself (Glaser, 1978). Doing grounded theory requires 
the researcher to multitask as there are several steps in the research process that take place 
simultaneously. While those steps are described separately below, they were used as 
required by the method to uncover the basic social process described in the data. 

Constant Comparison 

Constant comparison is a foundation on which grounded theory rests. Data are 
not analyzed in a linear fashion, but are instead revisited throughout the research process. 
In other words, the grounded theorist is on constant watch for patterns in the data by 
comparing incident with incident, incident with category, and finally category with 
category (Hutchinson, 1993). In this study, comparisons began with specific responses 
found within the transcribed interviews (i.e., incidents). Those comparisons lead to the 



50 
development of codes and categories that were subsequently compared to each other as 
well as other incidents. Constantly comparing the data in this fashion revealed the 
conditions, causes, and consequences of the revealed basic social process. That is, 
constantly comparing the incidents and categories enabled the researcher to see the 
conceptual connections and test their fit as an integrated substantive theory. 

Coding 

According to Glaser, "the essential relationship between data and theory is a 
conceptual code" (1978, p. 55). A theory is generated when the hypothetical relationships 
between codes are developed. Coding allows the researcher to fracture the data and then 
conceptually piece it back together to form the theory. Two types of coding occur during 
analysis. Substantive coding allows the analyst to conceptualize the empirical content of 
the research. Theoretical coding conceptualizes the fit of the substantive codes into the 
integrated theory (Glaser, 1978). While both types of coding occur throughout the 
research process, substantive coding occurs most frequently in the initial stages and 
theoretical coding in later stages. 

Initial substantive coding in this study was accomplished by reading each line of 
the transcripts of the first seven interviews and attaching codes to important words, 
phrases, and/or paragraphs. During this phase of coding I purposely coded without a 
preconceived list of ideas, an open coding procedure, resulting in a list of 162 codes. 
Subsequent to this, the complete list of codes was examined to determine whether some 
codes might be grouped together to form higher conceptual groups or categories. 



51 
Substantive coding continued with the next set of twenty interviews. However, at 
this point the coding focused on the use of the forty-four higher level codes developed 
from the first seven interviews. In addition to the use of the higher level codes, coding 
began to focus on the questions that Glaser (1978) suggests one ask: "What is this data a 
study of, what category does this incident indicate, and what is actually happening in the 
data" (p. 57). It was at this point in the process that the basic social process emerged. 

Once the basic social process emerged theoretical coding began. Data were 
examined to determine the conditions, causes, and consequences of the basic social 
process. This level of coding allowed the theory to become fully formed and integrated. 

Memoing and Sorting 

"Memos are the theorizing write-up of ideas about codes and their relationships as 
they strike the analyst while coding" (Glaser, 1978, p.83). Writing memos is at the core of 
doing grounded theory. Memoing allows the researcher to "to theoretically develop ideas 
with complete freedom into a memo fund that is highly sortable" (Glaser, 1978, p. 83). 
Through memoing the analyst is able to raise data to a conceptual level, develop the 
properties of each category, develop hypotheses about relationships between categories 
and their properties, begin the integration of ideas, and place the emerging theory among 
other theories of more or less relevance (Glaser, 1978). In this study, memoing began 
with notes describing the settings of the initial interviews, and the demeanor of the 
participants during the interviews. Also, memos were written as ideas emerged about new 
codes, the basic social process, and connections between categories. 



52 
Sorting begins when codes and memos are plentiful, and the basic social process 
has been identified. Through sorting the analyst is able to discern the relationship of the 
different levels of codes to the basic social process. From this sort an outline of the theory 
emerges and write-up begins (Hutchinson, 1993). 

Core Category 

The result of the steps described above and central to grounded theory is the 
discovery of a core category or the basic social process within the data. The goal is to 
generate a theory, centered on this category, which will account for a pattern of behavior 
which is both relevant and problematic for the group under study. In other words, the 
basic social problem of the group under study is addressed by the basic social process. 
The basic social process should account for most of the variation in the pattern of 
behavior found within the data. Also, most of the other categories and their properties 
will relate to the core category. Because of these relationships, the core category serves 
as the integrating point for the theory (Glaser, 1978). The basic social process discovered 
in this study, Pharmacist Interceding, is discussed in complete detail later in this work. 

Scientific Rigor 

Internal validity, external validity, reliability, and objectivity, are the criteria by 
which the rigor of a quantitative study is judged. Lincoln and Guba (1985) suggest, 
however, that because the nature of qualitative inquiry is different, a separate set of 



53 
criteria be used to judge the rigor of naturalistic (i.e., qualitative) inquiry. Their criteria 

includes assessments of credibility, transferability, dependability, and confirmability. 

Credibility, the qualitative researcher's equivalent to internal validity, is 
demonstrated when the researcher has shown that the findings and interpretation of those 
findings has "truth value" (Lincoln and Guba, 1985, p. 296) to those being studied. In this 
study, credibility was enhanced by the use of theoretical sampling, and concurrent data 
collection and analysis. Also, discussing the findings with colleagues and study 
participants provided a check on the truthfulness of the results. 

Lincoln and Guba (1985) suggest that the qualitative researcher cannot comment 
on the external validity of a study. Instead, the naturalist provides a thick description that 
will enable other interested researchers to make judgements about the transferability of the 
findings from one context to another. In this study, descriptions were written to provide 
the widest possible range of information. For example, the case studies presented in 
Chapter Six describe both the process of interceding as it occurs for the customer and the 
customer's relevant demographic and pharmacy experience information. This information 
will enable other researchers to judge how similar the current research context is to their 
proposed research context. 

Dependability and confirmability address the issues of reliability and objectivity. A 
determination of dependability and confirmability may be made through an audit process in 
which another investigator examines both the process and product of the inquiry (Lincoln 
and Guba, 1985). In this study, every effort was made to provide clear, understandable, 
and confirmable explanations of each step in the research process. 



54 
While the above criteria relate to qualitative inquiry as a whole, Glaser (1978) 
provides some specific guidelines for the evaluation of grounded theory studies. 
According to Glaser, "grounded theories have grab and they are interesting" (1978, p. 4). 
The theory must fit the area under study. Data are neither forced to fit pre-conceived 
categories, nor are they discarded just to keep a theory in place. The constant 
comparative method requires that data be compared and contrasted constantly, allowing 
an ongoing check on validity. A quality theory will explain the major behavioral and 
interactional variations in the area under study. The grounded theory must be relevant to 
the core variable that explains the social processes in the substantive area. That is, the 
individuals who are the actors in a particular setting should recognize the theory as being 
an accurate picture of the action. A good grounded theory is dense. There are a few 
theoretical constructs that are supported by a network of properties and categories, that 
are integrated to form a tight theoretical framework (Hutchinson, 1993). Finally, a 
grounded theory must be modifiable. While the basic social process remains stable, its 
variation and relevance may change quickly in the social world. Through coding and the 
constant comparative method, the grounded theory can be refined to account for new data 
found in further research (Glaser, 1978). 












CHAPTER 4 
FINDINGS: A MODEL OF PHARMACIST INTERCEDING 



Customers of community pharmacy participate in a medication use system that is 
often confusing and hard to negotiate. They walk into the door of their community 
pharmacy with a piece of paper (i.e., prescription) in their hands, having been given a 
range of details about the drug(s) they are about to take. The prescription is dispensed, 
there is some interaction with the pharmacist or other pharmacy personnel, and the 
customer is on his or her way home. But what about the customer's expectations for this 
pharmacy visit? 

This research shows that the complexity of the medication use system creates 
needs (the basic social problem) for community pharmacy customers. For community 
pharmacy customers, the needs created by the medication use system are addressed by the 
pharmacist acting on their behalf within the system. The pharmacist's acting, called 
interceding, is the basic social process which occurs in response to the customers' needs. 
Pharmacist interceding, which has phases of assessing and acting, is explained by the 
Model of Pharmacist Interceding. 



55 



56 
Customer Needs: The Basic Social Problem 

Thousands of customers enter community pharmacies every day. Some are 
picking up routine refill prescriptions, some are picking up a one time medication for an 
acute illness, and some are picking up new prescriptions for a chronic illness. For some 
customers the ideal pharmacy provides accurate and efficient service. For others, the 
addition of a personal touch is important. Regardless of these circumstances, all 
community pharmacy customers participate in the same complex medication use system, 
and at some point this participation creates a need(s) for the customer. Data from this 
study suggest that customer needs may be classified into three areas: the need for 
information, the need for a problem solver, and the need for reassurance. Because these 
needs may occur during any visit to a pharmacy, and because they will affect the 
customer-pharmacist interaction, it is important that they be examined. The remainder of 
this section is devoted to an analysis of the basic social problem of customer needs. 

Need for Information 

Customers enter the pharmacy with a variety of needs for information, ranging 
from a simple drug information printout to a detailed explanation of the best method for 
taking a medication. 

Informatio n Printouts. Many of the interviewees indicated that the drug 
information print-out that most pharmacies provide is useful. 



57 

Each medication came with a sheet that explained in greater detail and that was 
great. 

In fact one customer indicated that the printouts are even more important for maintenance 

medications. 

I like to get the detailed printout sheets, especially on maintenance, because ... I 
still like getting them because there might be things that you've forgotten about. 

Some customers are interested in even more detailed information about their medication 

(e.g., maximum dosage, name of manufacturer, how many different types of dosage). 

I want to know a lot, I want to know a lot. Because this is my body and if I'm not 
informed, then I inadvertently could do something that I wouldn't want to do. 

However one pharmacy customer did indicate that "you can go overboard and waste a lot 

of paper on things". In other words, this customer saw no need for the printout every 

time a prescription is refilled. 

Side Effects. Pharmacy customers seem to be particularly interested in receiving 

information about a medication's side effects. Learning about possible side effects 

prepares the customers for what lies ahead. 

It would help a lot. Not to have it come down on you suddenly, and you not know 
what drug's doing what. 

Parents, in particular, need advance warning about a possible side effect from their 

children's medication. "Is there anything I should notice about their behavior?" 

Additional Information. Pharmacy customers expressed a need for their 

pharmacist to inform them about any changes in the color, shape, or size of their 

medication. In addition, they want the pharmacist to inform them about any new 

information regarding their medication. Tips on administering medication are also 



58 
welcome. Finally, one customer suggested that pharmacies provide "an area of education 
while you're waiting." In other words, the pharmacy should provide a specific area in the 
store stocked with reading material about medications. 

Need for Reassurance 

To reassure may be defined as dispelling a fear or concern (The New Shorter 
Oxford English Dictionary, 1993). One of the problems that pharmacy customers face is 
the need to dispel any fears or concerns about their participation in the medication use 
system. Customers' needs for reassurance stem from three areas. They include emotional, 
dependability, and professional issues. 

Emotional Issues. Emotional issues may envelop a pharmacy customer as they 

enter the store. 

There is another thing too that I think that pharmacists and physicians should 
understand, is the emotional thing that you are going through from your illness. 

These issues range from wanting to talk to a need to feel safe. Customers understand that 

the pharmacist's job impacts their health, and because that is an important issue they need 

a pharmacist to care about them. 

Well it's concerning my health and my well being and the fact that someone is 
dispensing medication that could affect that health and well being, knows me and 
cares about what he is doing. 

Pharmacy customers need their pharmacist to understand their family problems, listen to 

their gripes, and teach them how to give their baby medication the very first time. When 

they are feeling bad they want a "little sympathy." They need their pharmacist to be aware 



59 

of their emotional state. 

I think a pharmacist [who] works with that pharmacy ought to be aware that there 
are times when you go into a pharmacy and you're distraught. I think they ought 
to show concern. 

Finally, pharmacy customers expect to find "someone you could trust" behind the 

pharmacy counter. 

Dependability. In addition to the emotional issues encompassing the pharmacy 

interaction, customers need to be reassured that they can depend on their care giver. The 

consistency of the pharmacist plays an important role in a customer's assessment of 

dependability. 

Not too many rotating pharmacists. I don't like that, that's why I go where I go 
because I like to know who I'm talking to. 

There was always a different pharmacist so there was no consistent person that 
knew me, and that knew the drugs that my daughter was on . . . and I did not like 
that. 

Customers want a pharmacist "that they can count on." They want to "know it's going to 

be the same people every time." Also, simple things like posting an emergency telephone 

number builds the customer's confidence in the dependability of the pharmacist. 

I like to know that if I got in trouble I could call - he has an emergency number to 
call his home. 

Professional Issues. Finally, customers need to be reassured that their pharmacist 

is a medication professional. They "want to know how up to date he is." They need for 

their pharmacist to be able to help them work through the costs versus benefits of taking a 

medication. 






60 

But when I talked to my doctor and talked to my pharmacist I realized that the 
benefits would outweigh, you know, what I was feeling at the time. 

Also, they need for their pharmacist to know their medication history and to act on it. 

I feel confidant that, that number one my pharmacist will question if he thinks that 
there is something that I might not be able to take . . . because he knows my 
history. 

In addition, customers want the pharmacist to respect their privacy and to provide follow- 
up care when needed. 



Need for a Problem Solver 

As stated previously, pharmacy customers face a complicated medication use 
system, and as with any complicated system problems develop. A variety of customer's 
problems were suggested, ranging from a perceived simple special order to complicated 
insurance issues. 

Special Orders. In one instance, an interviewee recounted the story of needing 
calibration solutions for her child's blood glucose machine. The customer visited one 
pharmacy prepared with the serial number of the machine and the number for the 
company, hoping that if the items were not in stock that they could be ordered. However, 
the customer indicated that the individual that she spoke with "didn't have a clue," and he 
"never really offered to order them." Fortunately the customer did not give up and she 
found a pharmacy that did not have the calibration solutions, but worked through the 
system and replaced the whole machine. Now the customer did not expect that the whole 
machine would be replaced, but she did need the first pharmacy to attempt to help. 



61 

If they had said we don't have it and we don't carry that, but we would certainly be 
happy to order it for you. Or to talk with our drug rep or whatever and get that 
for you. 

Vacation Supplies. Several problems stem from customers and their vacations. 

For example, one customer indicated that he had a difficult time in obtaining needed 

medication prior to leaving on vacation. His frustration was increased because he knew 

that the pharmacist could provide the needed help. 

I'm going away for three weeks, oh I'm sorry I can't fill it, you're not due for 
another two and a half weeks. A pharmacist who cares about the person he's 
dealing with or she's dealing with will find a way to do that. I've had it done for 
me. I know it can be done. Not all of them will do it. 

In another instance an interviewee spoke of a visiting friend and their frustration that the 

local pharmacist, an employee of the same pharmacy organization that she patronized at 

home, made no effort to contact her physician in order to verify and fill a Coumadin™ 

prescription. In a similar incident a customer recounted the story of being on vacation 

with her father. While on vacation in another state the father discovered that he had 

forgotten his blood pressure medication. They contacted his home pharmacy and 

requested that they send the medication to their location. "So he called down to the . . . 

and said I need you and they wouldn't send it." Not one to give up when she needed help, 

the daughter contacted her pharmacist, and explained the problem. She had a medication 

related problem and looked to her pharmacist as the problem solver. 

Physician Back-up. Customers often look to their pharmacist to solve or prevent 

problems caused by physician error. For example, one customer told of a time when she 

received the wrong strength blood pressure medication. It seems that the physician had 



62 

mistakenly changed the strength, but she expected her pharmacist to catch and fix that 

problem. While her pharmacist did not catch the problem, the customer still believed that 

the pharmacist was in the position to do so. In another instance a customer, with many 

medication allergies, relied upon her pharmacist to keep records that would prevent her 

from receiving a medication she was allergic to. 

Financial Issues. Many times throughout the interviews customers told of times 

when, for one reason or another, they felt they had wasted money when completely filling 

a prescription. One customer's mother seemed to have many allergic responses to 

medication. 

The pharmacist, suggested that he would give me a few pills when I got a 
prescription for her, give me only a few of the pills and see if she could tolerate 
them . . . Boy was that a lifesaver. Because I threw out so much medicine. 

In another case, the pharmacist discovered that the customer seemed to be allergic to the 

fillers found in many medications. The pharmacist suggested that this customer get a trial 

of two doses each time she had a new prescription, saving her money. 

Insurance Problems. Customers look to their pharmacist to solve all manner of 

insurance problems. One customer looks to the pharmacist to complete Medicare 

paperwork, "which is a boon to older patients." Another looks to her pharmacist to 

handle her Medicaid paperwork. 

See I'm on Medicaid and I don't take care of my paperwork. They absolutely do 
everything for me. ... if I didn't have [name of Pharmacist] I would just be 
floundering. 

For another customer the issue was whether his insurance company would pay for the 

brand name medication that he needed. This customer has a seizure disorder that is 



63 

regulated on a brand name medication. Generic drugs have not worked for him. So when 

his insurance denied payment for the brand name he looked to his pharmacist to solve the 

problem. 

I must have the brand name and that's the only one that works. . . . one of the 
biggest things that a pharmacist can do for you , is to perhaps, throw himself in the 
center and take care of details that you may or may not have the wherewithal or 
the knowledge to take care of properly. 

Customers also approach their pharmacist to solve problems regarding hard to get 
medications, and product malfunctions. One mother turned to her pharmacist when her 
infant son had a difficult time keeping his medicine down. Finally, customers often come 
into the pharmacy when they are truly hurting. These customers look to the pharmacist to 
fill their prescriptions on a priority basis, allowing them to return home to heal that much 
faster. 

Customers are faced with many unknowns each time they enter the pharmacy. 
Participation in a medication use system full of unknowns creates needs for those 
customers. Included are needs for information, needs for a problem solver, and needs for 
reassurance. Those needs are addressed by a process of pharmacist interceding. 
However, before the pharmacist can intercede or address the customer's problem(s), two 
conditions must exist. First the problem(s) must be recognized, and second the pharmacist 
must have the expertise to address the problem. Those conditions are discussed below. 



64 
Antecedent Conditions for Pharmacist Interceding 

The preceding sections describe a variety of customer needs, needs that the 
customer expects the pharmacist to act on. However, before the pharmacist may act or 
intercede for the customer two conditions must be in place. First, the need must be 
identified and second, the pharmacist must have the expertise to intercede. The sections 
below describe those antecedent conditions. 

Identifying A Need 

In order for the pharmacist to intercede on the customer's behalf, a need must be 
identified. Identifying the need occurs through the giving and receiving of a cue. A cue, 
according to Oxford's English Dictionary (1993) is a word or phrase which serves as a 
signal to another actor to enter the play. A cue, in the context of pharmacist interceding, 
operates in the same way. That is, a signal is given by an actor (e.g., a customer) to 
another actor (e.g., the pharmacist) to enter the play (e.g., the medication use system). 
Cues are the signal to start the process of pharmacist interceding and may come from any 
of three actors: (1) the pharmacy customer, (2) other pharmacy personnel, or (3) the 
pharmacist. 

The Pharmacy Customer. Cues to begin the process most often come from 
pharmacy customers themselves. All pharmacy personnel are possible targets for those 
cues. Straightforward cues may come in the form of questions. For example, one 
customer directly asked the pharmacist how to use his injectable medication. Another 



65 
asked the pharmacist about the best way to apply an eye ointment. Cues from customers 
may come from a statement made during a conversation with their pharmacist, and may be 
harder to detect. One customer indicated, during the regular course of conversation, that 
she was hoping not to take any pain medication. Still another described the allergy 
symptoms that she was having. 

Pharmacy Personnel. Other pharmacy personnel (e.g., technicians, cashiers) also 
participate in identifying needs. In a busy pharmacy they are often the first and last 
pharmacy contact for the customer. Customers may present questions to technicians or 
cashiers in hopes that they will be passed along to the pharmacist. While all the actors in 
the system receive cues, judging the seriousness of cues they receive may be more difficult 
for technicians and cashiers. For example, in one case a customer entered the pharmacy to 
pick up some medication. Fortunately, the technician noticed that the customer looked 
very ill (a cue), called for the pharmacist's assistance, and the customer was immediately 
sent to the hospital. However, if the relatively untrained technician had missed the cue, a 
bad result might have occurred. 

The Pharmacist. Cues may also originate within the pharmacist. Pharmacists may 
hear conversations between their technicians and customers that generate concern. They 
may notice a drug-drug interaction because they have access to customers' medication 
profiles. Finally, simply knowing the purposes and side effects of the medications 
themselves may generate a cue to act. 

Miscues. Cues without notice lead nowhere. That is, customers may ask 
questions, or come into the pharmacy looking extremely ill, but if pharmacy personnel do 



66 
not notice these cues (i.e., attend to them) then the pharmacist cannot intercede. For 
example, one customer mentioned a fear of taking pain medications during her 
conversation with the pharmacist. The pharmacist, however, missed the cue and missed 
an opportunity to address this customer's need for reassurance. In another instance, a 
customer explained that she was having breathing difficulties (the cue). The pharmacist 
heard the cue and went on to explain why her medications may be causing the difficulties. 

Pharmacist Expertise 

Examination of the interview transcripts shows that pharmacist expertise is a 
condition that must be present in order for the process of interceding to be successful. 
Pharmacist expertise is defined as the set of special skills and knowledge that pharmacists 
have obtained because of their training and educational backgrounds. 

Medication Experts. Pharmacist expertise includes the ability to understand drug- 
drug and drug-disease contraindications for both prescription and over-the-counter 
medications. One customer explained, "He said something about me picking up [over-the- 
counter remedy] one day and he goes, now did you read that pamphlet, that [over-the- 
counter remedy] sometimes has a reaction to [prescription medication]." Another 
customer explained. 

I'm sure he has to be heads up to any interaction type things that may be going on 
so that somebody hasn't actually written something that doesn't go with another 
thing. That you would run up a flag on the thing and say look this needs to be 
looked into before dispensing. 



67 

Expertise includes a knowledge of "how it [medication] affects you." In other words, 

pharmacists must be an expert in medication side effects. Pharmacists must have the 

expertise that allows them to confirm and extend any medication related information that 

customers receive from their physicians. 

It's also nice that if I go in and I have met with the neurologist and I'll say you 
know what she said about a drug, what do you think. 

But I've usually already asked the doctor and I'm looking for [the pharmacist] to 
confirm or relay any other things he has seen. 

In one instance a pharmacist declined to dispense a prescription that a patient had seen on 

a television advertisement and requested from her physician. The pharmacist recognized 

that the drug could cause harm and stopped the dispensing process. 

Customer Experts. Pharmacists must also be customer experts. Because they may 
be the one consistent health care professional that a customer visits, pharmacists must 
have the ability to understand and act on the medication history of the customer. For 
example, one customer suggested that "number one, my pharmacist will question if he 
thinks that there is something that I might not be able to take, that I shouldn't take or 
anything, because he knows my history. " 

System Experts. Pharmacists must also be experts in the medication use system. 
Pharmacists must understand the relationships between themselves and other health care 
providers. They must have a clear understanding of the rules under which they practice. 
Finally, pharmacists must understand the payment system for prescription medication. 
Evidence of the need for this type of expertise may be found in the interview transcripts. 
For example, one customer needed a specific brand name medication. His pharmacist had 



68 
to be an expert in the insurance payment system in order for that customer to receive his 
medication. In another instance a customer reported that her pharmacist would not leave 
her without medication for a day. This required the pharmacist to understand the working 
relationship between himself and the physician, and the rules under which he practiced. 



Summary 

Participation in a complicated medication use system creates needs for community 
pharmacy customers, and they expect those needs to be addressed by another participant 
in the system, their pharmacist. Included are the customers' need for information, for 
reassurance, and for problem solving. Pharmacists address those needs through a process 
of interceding, but two conditions, identification of the need and pharmacist expertise, 
must be present prior to the act of interceding. The process of pharmacist interceding is 
discussed in the following chapter. 



CHAPTER 5 
PHARMACIST INTERCEDING 



Interceding may be defined as acting on behalf of another. Specifically, in this 
study, interceding refers to the pharmacist acting on behalf of a customer in our 
medication use system. Because interceding is a process, not a static event, a series of 
phases occur. Data from this study showed that the process of interceding has two 
phases: (1) assessing, and (2) acting. Each is discussed below. 

Assessing 

Once a problem has been identified the process of pharmacist interceding may 
begin. The first phase in this process is assessing. During the assessing phase of 
interceding the pharmacist works to understand the real issue underlying the identified 
problem. That is, the pharmacist evaluates the identified problem. 

The process begins, says one pharmacist, with an effort to let the customer know 
that they have the full attention of the pharmacist. The pharmacist focuses on the 
customer and attempts to relay the feeling that she is receptive and willing to talk. This 
pharmacist finds that customers are more willing to talk, and "give you the whole story" 
when they feel comfortable. Once the customer is talking, assessing may begin in earnest. 

69 



70 
During conversations with customers, pharmacists said that they listen to the 
questions posed by their customers. They assess the customer's level of comprehension 
through responses to their questions, the language used, their past history with the 
customer, and the apparent educational level of the customer. Pharmacists echo back the 
customer's responses in an effort to make sure that they really understand the customer. 
While echoing back the customer's statements, the pharmacist gets clues from body 
language and facial expressions. These clues allow the pharmacist to judge the customer's 
receptivity and understanding of what they are discussing. 

Once the pharmacist is sure of the issue at hand, an internal assessment begins. 
That is, the pharmacist asks, do I have enough information, do I have enough knowledge, 
should I look something up, or should I make a referral? The pharmacist is concerned that 
the right response is provided. When the pharmacist fully understands the issue at hand 
and feels capable of handling the issue, interceding moves to the acting phase. 



Acting 



Acting on an identified customer need is the core of pharmacist interceding. 
Without action there is no process, no interceding. Because of the wide range of needs 
expressed by customers, pharmacists act in a variety of ways. Their actions may be 
categorized as follows: (1) problem solving, (2) educating, and (3) reassuring. 



71 
Problem Solving 

The need for problem solving generated the most diversity in pharmacist action. 
Examples found in the data include completing Medicare paperwork, providing a delivery 
service, and opening charge accounts for customers in need. While pharmacy customers 
report a wide variety of problems, two categories of problems seem to emerge. They are 
(1) problems stemming from the bureaucracy of the medication use system, and (2) 
problems stemming directly from the use of the products found in a pharmacy . 

The Bureaucracy. The medication use system is no different than any other large 

system. It has layers of bureaucracy that create problems for those involved in the system. 

Pharmacists are constantly called upon to work through the layers and solve their 

customer's problems. For example, pharmacists often work to solve insurance problems. 

These problems may include making sure the customer has a vacation supply of 

medication, getting the customer a needed brand name medication, and assisting the 

customer with a new plan. One customer needed a new blood glucose machine for her 

child. The pharmacist provided and participated in the step by step procedures required 

by the insurance company. 

Well we don't carry those any more, but if you will go over to the pediatrician and 
get another prescription for it we'll give you a new kit and it was free . . . She gave 
me a solution. 

Pharmacists often act to make sure that their customers do not go without 

medication. This may occur because a physician has not answered a request for a refill or 

because a customer simply forgot to call the refill order in on time. For one customer 

solving the problem meant having access to experimental seizure medications for her 



72 
daughter. The pharmacist was able to help. "I can remember being on experimental drugs 
and [the pharmacist] was able to get them." In another case a customer's car was stolen. 
The pharmacist was able to replace the medication stolen along with the car. 

One customer recounts a story of being in great discomfort from a medical 
procedure. At home, she noticed that she had mistakenly asked the pharmacist to fill the 
wrong prescription. She returned to the pharmacy, explained her problem to the 
pharmacist, and he promptly filled the needed prescription. 

I guess that he saw that I was in so much pain and remembered that I was there 
. . . what he did was, on his own, went on and filled mine, okay while there were 
other people there so I could leave. 

In each of these cases the pharmacist understood and worked through the rules of the 
particular bureaucracy to solve the customer's problem. 

Product Use. A variety of products may be found in any community pharmacy, 
and the use of those products creates a variety of problems. Several customers reported 
having numerous allergies to medications. These allergies created possible health and 
financial problems for the customer. The pharmacist was able to alleviate these problems 
by: (1) dispensing only a few pills at the first dispensing of a new prescription, and (2) 
keeping and using computer records which allowed him to keep a watch for any possible 
problems. Pharmacists may also act to solve problems of medication compliance. For 
example, a shorter duration antibiotic was suggested to a Mom whose child fought taking 
medicine. Some customers may have a problem choosing an appropriate over the counter 
therapy. The pharmacist is able to assist the customer in a choice of over the counter 
medication. 



73 

I told him what was going on and he knows I have to take blood pressure 
medication, so he watched that and you know, he went out on the floor there and 
he looked at different possibilities. 

Finally, one pharmacist reworked a durable medical equipment item so that it would fit his 

customer's thumb. 

If I've got a particular problem ... not to long ago I had tendinitis in my thumb, 
and I was just at a loss. I kept trying to find ... a splint for my thumb . . . and the 
pharmacist said, I think I've got something that will work. And he fooled around 
with it until he got it to work. 



Educating 

Pharmacists act to educate their customers in several ways. An assessed need for 

information may be met by providing the customer with a drug information sheet. 

I have noticed that every time that I have gotten a new medication I also at the 
same time get a computer printout with it that has all kinds of interactions, 
notifications, and warnings of any kind, side effects and things of that nature. And 
yeah, sure that's a great thing to have in there. 

In some instances the pharmacist educates through conversation. One customer said "he's 

gone into his big book and read things to me." In other instances, the pharmacist educates 

by demonstrating. For example, pharmacists are frequently called upon to teach people 

how to properly administer medication. One pharmacist was observed showing a 

customer the correct technique for using an injectable medication. In another instance the 

pharmacist taught a Mom how to give an infant medication. 



74 

Reassuring 

Pharmacists reassure their customers in a variety of ways. One customer, who 

indicated that she always checks her health care providers credentials, was reassured 

because "his credentials are on the wall." In another case a customer was reassured by the 

reaction of the pharmacist to a mistake made in his pharmacy. 

It's a terrible thing that happened ... I mean I can't dismiss the severity, but they 
were responsive right away . . . come in and get what you do need, you know, it's 
not oh, we're sorry. You know they helped me all the way through it. 

The customer felt that because of the pharmacist's reaction to the mistake, pharmacy 

personnel would be more careful in the future. Pharmacists reassure their customers when 

they make themselves available for questions. They reassure their customers when they 

come from behind the counter and sit down to explain and show a mother how to 

administer drugs to a fussy infant. 

I was just so upset and frazzled over the whole thing. He made me comfortable 
about giving him that medicine and stuff ... By talking to me and he came out and 
actually went into his [the baby's] pumpkin seat and said let me show you how you 
could give it to him and he did an eyedropper with a little bit of water and he said 
if you put it into the side, he said almost like a kitten and blow on his nose a little 
bit, he'll swallow. 

Customers are reassured when their pharmacist pre-warns them about changes in their 

medication. For example, one customer spoke of a change in the manufacturer of her 

child's medication. She was glad that her pharmacist informed her of the change before 

she left the store, alleviating the anxiety that she might have felt later without the warning. 

Customers are reassured when their pharmacist acts to show concern. For one customer 

this meant that the pharmacist called to make sure that she was taking her medicine 









75 
correctly. For another customer it meant the pharmacist taking her for medical care. 
After that event the customer was surely reassured that the pharmacist would look out for 
her well-being. Finally, one customer indicated that she was reassured that the pharmacist 
respected her privacy, because he had never asked any invasive questions. 

Pharmacist interceding is a complex process that goes on in an ever changing 
medication use system. Because pharmacist interceding takes place in a system of care, a 
variety of conditions may influence it. They are discussed below. 

Conditions Influencing Pharmacist Interceding 

The process of pharmacist interceding takes place in a complex medication use 
system. Therefore, there are several surrounding conditions which influence interceding. 
Influencing conditions discovered within the data include the pharmacy environment, time, 
social structural variables, and the personalities of both the pharmacist and customer. 
Each is discussed below. 

Pharmacy Environment 

Community pharmacies may be found as stand alone units, as departments within a 
grocery store, in clinics, and as departments within a general merchandise store. Because 
pharmacies are located in many different types of establishments a variety of environments 
surround the pharmacy. This variety of environments and the specifics of the pharmacy 
set-up may influence the process of interceding. Included as factors in the pharmacy 



76 
environment are the physical set-up of the pharmacy, the focus of the establishment that 
includes the pharmacy, and the number and types of personnel working within the 
pharmacy. Each is discussed below. 

Physical Set-Up. While pharmacies have some common physical features, not all 
are set-up in the same way. For example, the dispensing area of the pharmacy is most 
often found behind a counter of some sort. However, in some pharmacies the dispensing 
area is also on a raised platform, or behind glass windows, or beyond a window, or two 
counters back. Because the pharmacist operates in the dispensing area, this physical 
location becomes an important issue for interceding. Observations of pharmacists at work 
confirmed this point. For example, in one pharmacy the pharmacist was generally found 
working at a dispensing counter on floor level, with no other barriers. This pharmacist 
was constantly involved in the interactions with customers. With this easy access 
dispensing area, customers were able to easily cue the pharmacist when a need arose. In 
addition, the closeness of the pharmacist to the customer enabled her to initiate interceding 
as she judged necessary. Contrast this with the pharmacy in which the dispensing area is 
located two counters back. That is, in one of the observed pharmacies, the pharmacist 
primarily worked at a dispensing counter which was located behind the main pharmacy 
counter. While this physical set-up may create an efficient dispensing process, it places 
two physical barriers between the customer and pharmacist. Observations in this 
pharmacy showed that it was difficult for customers to directly cue the pharmacist. In 
fact, at one point, thirty-five minutes elapsed before an interaction between a pharmacist 
and customer was observed after the pharmacist dispensed the customer's medication. 



77 
Physical barriers may not always interfere with the process of interceding. In one 
pharmacy, where the dispensing area was located on a raised platform, one customer was 
not deterred. He simply placed his prescription on the top of the counter and spoke with 
the pharmacist. In this same pharmacy, the pharmacist consistently greeted customers 
from the platform, almost as if it were an observation post from which he could keep an 
eye on the pharmacy. Rather than deterring interaction, the platform seemed to facilitate 
interaction. 

Pharmacy Focus. The focus of the store in which the pharmacy is located may also 
influence the process of interceding. Some pharmacies are departments within stores that 
sell a wide variety of merchandise, and some are within stores that focus on medicine and 
other health related items. One customer indicated that "you go into some of them . . . 
and it's just a little department shoved in the back somewhere. And that doesn't feel 
important enough to me." For this customer, the focus on medicine signals that it is okay 
to express a need for pharmacist interceding. Customers who patronize a pharmacy that 
focuses on health care more often described their pharmacies as warm, homey, or 
comfortable. Perhaps this environmental factor enables the customer to feel comfortable 
expressing a need. 

Pharmacy Personnel. Another environmental factor which may influence 
pharmacist interceding is the number and types of personnel working in the dispensing 
area. Pharmacies tend to employee three types of personnel to work within the dispensing 
area: pharmacists, pharmacy technicians, and cashiers. Clearly the addition of layers of 
personnel between the pharmacist and customer may influence the process of interceding. 



78 
In one store that employed all three levels of personnel, customers had infrequent chances 
to cue the pharmacist about a need. The levels of employees acted as a barrier to the 
pharmacist. That is, customers generally interacted with cashiers or technicians before they 
were able to interact with a pharmacist. However, in another three level store, the 
pharmacist had frequent interactions with customers. This may indicate that the number 
of employees between the pharmacist and customer becomes a barrier only when other 
factors come into play. Those factors might include store policy and pharmacist time. 

Time 

The process of pharmacist interceding may be affected in several ways by time. 
That is, time is a multi-faceted issue that affects both customers and pharmacists. 

Customer's Time. Effective use of time is important to customers. One customer 

indicated just how important her time is. 

The other one [insurance plan] would cost me less money out of my paycheck each 
year and I chose to pay, more money to stay at [name of pharmacy]. That's how 
valuable my time is. 

This customer had previously related instances in which she felt her time had been wasted 

at other pharmacies. She chose a pharmacy where she perceived the wait time was low. 

Other customers also indicated that they are interested in fast service. This desire for fast 

service may adversely affect the pharmacist's ability to appropriately intercede on the 

customer's behalf. 

Pharmacist's Time. Pharmacist's interceding is also affected by the amount of time 

available for the process. The amount of time available may be affected by the 






79 
prescription volume of store as well as the assignment of personnel to the various 
dispensing tasks. For example, in one high volume store the pharmacists had little time 
available for interactions with customers. Most of the pharmacists' time was spent filling 
prescriptions and answering phone calls. Cashiers and technicians were assigned the tasks 
involving direct customer contact, not the pharmacist. However, in another high volume 
store the dispensing tasks were set up so that the pharmacist did have time to intercede. 

Social Structural Variables 

The medication use system is replete with social structural variables that influence 
pharmacist interceding. Those variables seem to fall into two categories, government 
regulations and insurance regulations. 

Government Regulations. Government regulations, both state and federal, provide 
the pharmacist with a practice template. That is, those agencies decide and subsequently 
describe how a pharmacist is to practice pharmacy. One regulation that may affect 
pharmacist interceding is the requirement that all pharmacy customers be offered 
counselling (i.e., the chance to talk to a pharmacist). In some pharmacies the cashier or 
technician makes a verbal offer to the customer. Imagine the observed difference between 
an offer of, "you don't have any questions for the pharmacist do you," and "what questions 
do you have for the pharmacist today?" The first question places an obstacle in the way of 
interceding, the second opens a direct path for the pharmacist to intercede. 

Insurance Regulations Insurance rules and regulations also affect the process of 
pharmacist interceding. In today's medication use system, most customers' prescription 



80 
insurance claims are adjudicated online. That is, the insurance claim is electronically 
transmitted to the insurance company as the prescription is being filled. The pharmacy 
knows immediately whether the prescription is covered or not by the customer's insurance, 
and in some instances the pharmacist is provided with additional information. This online 
adjudication provides an opportunity for the pharmacist to intercede in several ways. For 
example, when one drug is not covered the pharmacist knows immediately and he may 
suggest another medication. In another instance the customer may be patronizing several 
pharmacies, online adjudication may reject a prescription because of an interaction with a 
drug dispensed at another pharmacy. The pharmacist may then act to suggest a different, 
more compatible medication. Insurance regulations may also act to hamper a pharmacist's 
ability to intercede. For example, insurance companies dictate the quantity of medication 
that a pharmacist may dispense. They may also provide a formulary of covered 
medications. 

Personal Characteristics 

A final factor that may affect the process of interceding is personality type of both 

the pharmacist and customer. Time and time again customers stated that they want their 

pharmacist to be friendly, to be polite, and to take a personal interest. 

But he is a very personable person and he seems to take an interest in all people. 
He calls most people by name, that I like. 

A seemingly open and friendly pharmacist may open the way for a customer to express a 

need. However, the personality of the customer may be just as important to the process. 



81 
For example, one customer indicated that her pharmacist "appears to be very stiff, but he's 
very nice to me. Very nice to me." Perhaps this customer's personality, open and friendly, 
allows the pharmacist to be open to the possibilities of interceding. 

Summary 

Because of the complicated medication use system in which they participate, 
pharmacy customers develop needs. Those needs include a need for information, a need 
for reassurance, and a need for a problem solver. Together they comprise the basic social 
problem that pharmacy customers face. The basic social process which addresses those 
needs is pharmacist interceding. Pharmacist interceding may be defined as the pharmacist 
acting on behalf of a customer in the medication use system. Pharmacist interceding as a 
process includes the phases of assessing and acting. The process is preceded by two 
conditions, problem identification and pharmacist expertise, and it is influenced by a group 
of factors including, pharmacy environment, time, social structural variables, and personal 
characteristics. But what happens after the pharmacist intercedes? What are the 
consequences of pharmacist interceding? That final piece of the model is discussed in the 
following chapter. 















CHAPTER 6 
THE CONSEQUENCES OF PHARMACIST INTERCEDING 



Pharmacy customers present their pharmacists with a variety of needs, and 
pharmacists respond to these needs by interceding or acting on behalf of their customers in 
our medication use system. But what are the consequences of that interceding? Data 
from this study indicate that a relationship is formed between customer and pharmacist. 
That is, a connection or association is formed between the two. While some 
commonalities among the data were found, not all customer- pharmacist relationships are 
alike. Findings from this study show that relationships may be classified into one of two 
types: professional and personal. In the following sections, a description of the two 
relationship types is presented. This is followed by six cases or in depth descriptions of 
the processes described by the Model of Pharmacist Interceding. 

Professional Relationships 

The formation of a professional relationship between customer and pharmacist 
seems to be common to all pharmacy customers. In other words, the minimum 
consequence of pharmacist interceding is the formation of a professional relationship 
between the customer and pharmacist. For this study, a professional relationship may be 



82 



83 
defined as an association between pharmacist and customer which focuses on the 
customer's medication use. This relationship is role based, and is formal in nature. In a 
professional relationship, there is recognition of the partners and a purposive exchange. 
Pharmacists and their customers recognize each other, have some affinity for each other, 
but focus their interactions on getting the prescription dispensed: accurately, efficiently, 
and safely. 

Personal Relationships 

Personal relationships may also be a consequence of pharmacist interceding. While 
personal relationships included some of the same elements as a professional relationship 
(i.e., recognition and accurate, efficient, safe prescription dispensing), they also include an 
increased level of personal involvement. Pharmacy customers who formed a personal 
relationship related instances in which their interactions with their pharmacists included 
discussions of family and work matters, and they more often referred to their pharmacist 
as a friend. Also, at this level, customers reported that their pharmacist acts to provide an 
extra degree of service. 



Cases 



So that the reader may have a better understanding of the consequences of 
pharmacist interceding as well as the Model of Pharmacist Interceding as a whole, the 



84 
remaining section of this chapter includes six case descriptions. The cases were chosen 
because they illustrate a range of customer needs, pharmacist action, and type of 
relationship formed. Cases one, two, and three describe instances in which a professional 
relationship is formed. Cases four, five, and six illustrate the process as it ends in a 
personal relationship. 

Case One 

At the time of the interview Bonnie* was a sixty-three year old semi-retired 
certified nursing assistant (CNA). She visited her pharmacy, a chain store, every week on 
average, due in part to her job as a CNA. While she does have two chronic illnesses, she 
characterized her health status as good. Bonnie bears the entire obligation of paying for 
her medication. Her story provides us with an example of the progression from customer 
needs through pharmacist interceding to building a professional relationship. 

Throughout her interview, Bonnie expressed needs for information. For example 
she suggested that the pharmacist should make you aware "you can have reactions by 
taking this medicine." Also, she indicated that the pharmacist was the one to ask about 
medications that she wanted to try. She found "that the pharmacist has a lot of update on 
the medicines that doctors don't have," and with this statement revealed one of the 
conditions for interceding, that is pharmacist expertise. 

Bonnie's expression of her need for information, a question for her pharmacist, is 
an example of customer need identification. Bonnie cued her pharmacist that she needed 

all names are pseudonyms 



85 

some interceding, but in this case the process ended. 

I've went to the drugstore before and asked a pharmacist, well what do you think 
about a certain drug. And the pharmacist would say well it's up to the individual. 
Well I didn't want that answer. I wanted an answer like well have you ever taken 
this or that and how did it react? Well this is the one I think, why don't you try this 
one? I think he should be more knowledgeable and more information, give you 
more information. 

This pharmacist did not attend to Bonnie's cue, resulting in no interceding. Bonnie tells of 

another time when she visited her pharmacy. 

I got a prescription one day and I didn't understand it and he didn't have time to 
tell me about it. So I thought oh well, he'll give me a slip and I'll know a little bit 
more about it, but he didn't. So I started going to a drugstore that was farther 
away, but they talked to me when I went in. 

This time Bonnie had a need for information that was not met. The pharmacist did not 

intercede so Bonnie went looking for a pharmacist who would meet her needs. Bonnie 

goes on to say that "the next time I had to have a prescription filled I tried them (again). I 

liked the way they explained things to me." This new pharmacist was able to identify, 

assess, and act (i.e., intercede) on Bonnie's needs. As a result of the interceding, a 

professional relationship has formed between Bonnie and her pharmacist. 

I would want to go where I liked the pharmacist. Because the pharmacist I was 
going to just got a new job so I may switch. 

Bonnie is willing to change pharmacies so that she has the opportunity to work with the 

same pharmacist. 






86 
Case Two 

At the time of her interview, Joan was a thirty-nine year old human resources 
generalise She visited her independent pharmacy four to six times each month. Joan 
characterized her health status as good even though she has a chronic illness. She shares 
prescription payment obligations with her insurer. Her story provides us with an example 
of pharmacist interceding that leads to a professional relationship. 

Joan classifies herself as a "very informed medical patient. Because I have a lot of 

things wrong with me." This classification drives her need for information. Because they 

know her, Joan's pharmacist will provide her with specific information tailored to her 

medication profile. 

They will mention, don't forget, you need to take this with food, because of your 
bad stomach. Okay, or you've never had this before, this may make you drowsy. 

Joan also relies on the information sheets provided with each prescription. She reads 

those sheets from beginning to end every time she has a prescription dispensed, and she 

calls her pharmacist if she has any questions. 

Oh, I would never call the doctor. . . . Because, you know what, the pharmacy 
knows more about drugs, I think, than the doctor does. Especially the interactions 
to be perfectly honest with you. 

Joan also indicated that from time to time she has the need for a problem solver. 

She tells of one instance when she had injured her back. Two prescriptions were phoned 

to a pharmacy and even though she was in pain she was told that the wait for the 

prescriptions would be an hour and a half. Joan had a problem, pain. In this case, the 

pharmacist did not identify or cue into the pain. Therefore there was no interceding and 












87 

no relationship. In fact, Joan called the pharmacy supervisor for this pharmacy to relay 

her displeasure. She indicated that she will not return to that pharmacy. However, Joan 

does tell of a pharmacist that will help her solve this same problem. 

And when you bring in a prescription for pain medicine or something he knows 
where you need it right away. He'll bump your prescription up, so that's nice. 

Joan knows the name of her former pharmacist and "he remembers my name" even though 

she moved and he has not been her pharmacist for six years. 

Time is a very important issue in Joan's life. In fact, one of the reasons that she 

patronizes her current pharmacy is the efficiency with which they dispense her 

prescriptions. They have recognized that wasting time is a big problem for Joan and they 

have acted to solve the problem. 

They are fast and let me tell you, what has kept me there. Something in addition 
to that. That this year we have more than one type of HMO [health maintenance 
organization] that I like. It's a point of service HMO and we have two this year to 
choose from. The other one would cost me less money out of my paycheck each 
year and I choose to pay more money to stay at [name of pharmacy]. That's how 
valuable my time is. 

Joan has formed a professional relationship with the pharmacist who values her 

time, provides her specific drug information, and respects her privacy. 

Case Three 

George was a forty-three year old project director at the time of his interview. 
Like Bonnie, George patronizes a chain pharmacy, but very infrequently. He says his 
health status as "somewhere between fair and good." His insurer covers the complete cost 
of his medication. George's story illustrates the formation of a professional relationship. 



88 

While George is an infrequent patron in his pharmacy, he did express a need for 

information during his interview. 

Tell me about the medication. What are the side effects, how do you take it, if 
there, if you should take it with dinner, with water, what not to take it with, so 
that, you know there's obvious stuff like don't take it with alcohol, but if there's 
other things that you can take it with that could possibly make you sick of 
something, or queasy or uncomfortable. . . . And if they are aware of other 
medications that are out now that will address the same or similar issues. 

George expects his pharmacist to be able intercede and provide this information. He tells 

of a time when he had a need for information and the pharmacist did not help. 

I started asking questions and they couldn't answer it, they didn't know and as a 
consequence I thought they didn't know and that was the reason for their being 
curt with me. I'm trying to find out what I need to know and they were well your 
doctor gave it to you isn't that sufficient. 

In this case, the pharmacist did not identify and act on George's need for information. 

When asked how the pharmacist could have made things better, George replied as follows. 

Answer my questions. And not tell me, if you don't know, it's perfectly okay to 
say you don't know. . . . Just say well Mr. X I'm really not sure. It would probably 
be best if you could talk with your doctor about this in more detail. And that's 
fine. Then I can choose to come back or not come back to that pharmacy. 

George currently patronizes a pharmacy where he likes "this place because the guy 

explains everything." The pharmacist is "friendly and open." Also, he remembers a 

pharmacy in another city "where the guy would explain what you had, but it wasn't like I 

was talking to my best friend or anything, but he did his job." This last sentence seems to 

summarize George's professional relationship with his pharmacist. That is, he has a need 

for information, and the pharmacist acts to meet that need in the context of the 

professional relationship between customer and pharmacist. 



89 
Case Four 

At the time of her interview, Moira was a fifty-two year old disabled medical 
technician. Moira suffers from an illness that does not allow her to work. She patronizes 
her independent pharmacy at least monthly, and her prescriptions are completely paid for 
by a third party. 

While Moira expressed needs for information, the clearest depiction of relationship 

building stems from her need for reassurance. 

I checked and [name of pharmacist] was there and I was glad. ... He knows all of 
my medicines and he knows what to tell me about them or if there are any 
problems about them. 

Having one pharmacist available reassures Moira that "they know her and they pay 

attention to what you're doing." 

Not too many rotating pharmacists. I don't like that, that's why I go where I go 
because I like to know who I'm talking to. 

Moira has clear evidence that her pharmacist pays attention to what she is doing. 

I mean one day, I'll just tell you, I was very sick in the pharmacy and [name 
of pharmacist] saw that I was because he knows me, he just took me to the 
hospital. . . . But the point is that he saw it, he recognized it and he knew that I 
needed to go and he helped me. 

In this instance, the pharmacist identified the customer's physical state, assessed the need 

for immediate medical attention, and interceded by getting the customer the needed 

medical care. Moira feels certain that her pharmacist would act to help her, no matter 

what. 

If [name of pharmacist] couldn't have done it, he would have found someone who 
could have done it. 






90 

Because of the interceding Moira has formed a personal relationship with her 

current pharmacist. 

I go down to Shands and [pharmacist] familiar with that. He knows what's going 
on. He knows that partly because I've told him and he's listened and remembered. 

Case Five 

Betty was a sixty-one year old homemaker at the time of her interview. She 
patronizes an independent pharmacy, and visits about every two weeks. She does have 
some chronic illnesses, but says she is in good health. Betty shares the responsibility of 
payment for her medication with her insurance company. 

Betty expressed all three needs throughout her interview. She looks to her 
pharmacist to solve problems with insurance coverage, out of stock items, and vacation 
supplies of medication. She needs her pharmacist to provide her with extensive drug 
information, to advise her of interactions with her current medications, and to suggest 
over the counter medications. Betty needs reassurance that her pharmacist "is up to date 
on his, with the knowledge of medicines that are coming up." This reassurance comes in 
the form of credentials in plain sight. Betty wants her pharmacist to show concern when 
she comes in distraught. She also revealed the condition of pharmacist expertise during 
our conversation when she said that her pharmacist should "be an expert in what type of 
medicine he's giving me." 

Throughout our conversation Betty shared several instances that provided a 
pharmacist the opportunity to intercede. 



91 

I went to a particular pharmacy, presented my prescription and my medical card, 
my medical insurance card and 1 was promptly told we don't take this medical 
insurance. Do you know where I can go to get this filled? I was under the 
impression that you did take it, well we don't. End of subject, end of conversation 
and their back was turned to take care of someone else. 

Betty needed someone to help her solve her problem, but instead she found a pharmacist 

who missed a cue. Betty ultimately solved her own problem by going to another 

pharmacy, but the first pharmacy missed an opportunity to build a relationship with Betty, 

and has now lost her as a customer. As Betty said "now I would not go in there, I just 

wouldn't, I just would not do it." 

Betty relates another instance in which a pharmacist had the chance to solve a 

problem by using his expertise and interceding. 

I called, I had a hard time breathing, I had post nasal drip there in the back. And I 
get really stuffed. Well I don't need to go to the doctor to find out about that, but 
I can call my pharmacist and say look I feel this. My head is hurting, I know you 
can't prescribe . . . but I would say, what is there over the counter that you can tell 
me that I can take and he'll ask me well what are the symptoms, I tell him, he tells 
me what I can buy over the counter. . . . That saves me a trip, an unnecessary trip 
to the doctor. ... it makes me feel like I have somebody I can go to, over the 
phone, that is going to help me. 

Clearly in this instance the pharmacist acted on the cue given by Betty, and in this case a 

relationship has been developed. Betty patronizes the pharmacy where this pharmacist 

works. Like others who formed a personal relationship, Betty described the pharmacy as 

having a "homey atmosphere" and being treated as if "we're old friends." 












92 
Case Six 

At the time of the interview, Ann was a sixty year old paralegal. Ann visits her 
independent pharmacy about three times a month. She does have a chronic illness but 
characterizes her health as good. Ann shares payment responsibilities with her health 
insurance company. 

Like Betty, Ann expressed needs in all three categories. She expressed a need for 

information about new products, and a need for her pharmacist to recommend an over the 

counter product. Ann needs to be listened to when she was feeling bad, and to feel safe in 

her pharmacist's choices. She also needs her pharmacists to help her solve problems. For 

example, Ann was having difficulty taking medications. It seems that she was allergic to 

them. It was her pharmacist, however, that "determined that I was allergic to fillers, not 

so much the medication but the fillers." Finally discovering the source of the allergy was 

important, but the allergy problem was still present. So, Ann's pharmacist interceded 

again. 

And what we did, and he suggested it, when would get a prescription for a drug, 
he would give me two pills, and he said use this ... If it worked, then he would go 
ahead and fill the prescription. 

Ann reports other instances in which her pharmacist interceded. At one time she spent six 

weeks looking for a splint for her thumb, but found none that fit. Her pharmacist upon 

learning about the problem, "fooled around with it until he got it to work." At another 

time her pharmacist assisted her in getting medication for her father while they were out of 

town. 



93 

Each of these instances of pharmacist interceding builds on another, creating a 

long lasting personal relationship between Ann and her pharmacist. 

Personal service is just what I said, the relationship I have with the pharmacist in 
cooperating with me and not, and in knowing me . . . I've been trading there since 
1977. 

Pharmacy customers present their pharmacists with a variety of needs. Those 

needs give the pharmacist the opportunity to intercede on their customer's behalf. The 

cases outlined above show that the consequence of pharmacist interceding is the formation 

of a relationship between the pharmacist and the customer. 









CHAPTER 7 
SUMMARY AND RECOMMENDATIONS 



Summary 



The purpose of this research was to generate a substantive theory that explains 
customer expectations of community pharmacy services. Using the grounded theory 
approach, pharmacy customers were interviewed and observed in order to identify and 
understand the basic social problem they face as well as the basic social process used in 
addressing the problem. 

Pharmacy customers participate in a medication use system that is complex and 
confusing. The complexity of the system creates a set of needs for pharmacy customers. 
Findings from this project show that the basic social problem of needs is addressed by the 
basic social process of pharmacist interceding. In response to customers' needs the 
pharmacist engages in a process of interceding that results in a relationship between the 
customer and pharmacist. Pharmacist interceding, which is explained by the Model of 
Pharmacist Interceding (Figure 1) includes the phases of assessing and acting. The 
formation of a relationship between the pharmacist and customer is the outcome of the 
process of interceding. 



94 








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96 
Each component of the Model of Pharmacist Interceding makes an important 
contribution to understanding customer expectations, keeping in mind that customer 
expectations are part of an interaction process. The basic social problem of customer 
needs provides us with the starting point of understanding. Customers enter the pharmacy 
with some need(s). These needs act as a precursor to the customer's expectation(s). In 
other words, a customer with needs has the expectation that their pharmacist will act on 
their behalf (i.e., intercede) in the medication use system. If we understand the needs, then 
we are able to teach the pharmacist to recognize them. 

The next component of the Model includes the basic social process, pharmacist 
interceding. Understanding that pharmacist interceding has the phases of assessing and 
acting provides another opportunity for intervention. That is, we can teach the pharmacist 
how to recognize cues, assess them, and act on them in order to meet the customer's 
expectation of intercession. In addition, pharmacist interceding takes place in a 
medication use system that imposes certain conditions on the process. Understanding the 
issues of pharmacy environment, time, social structural variables, and personality type 
provides the pharmacist an opportunity to keep a watchful eye for any effect on 
interceding. 

The final component of the Model is the outcome or consequence of pharmacist 
interceding, the formation of a relationship between the customer and pharmacist. 
Knowing that a relationship is the outcome of interceding shows the pharmacist the 
importance of interceding. 



97 
Relationship of the Model of Pharmacist I nterceding to Other Research 

The expectations construct has been studied over a period of many years, with 
varying results. The Model of Pharmacist Interceding is not meant to replace previous 
work. Instead this Model will act as an adjunct to improve the outcomes of expectations 
research. Previous work in expectations has a primarily deductive origin. That is, the 
research process was designed to test hypotheses based on a specific theoretical 
perspective. The development of this model followed the grounded theory method. 
Grounded theory uses an inductive approach in order to provide an explanation for 
behavior. In other words, the developed theory is grounded in the study data. This new 
approach to expectations research provides several advantages. For example, the actors in 
the process provide the data from which the theory or model is built. This allows for a 
theory that describes the problems and processes that are important to the participants. 
Also, the grounded theorist is not tied to another researcher's ideas. In grounded theory 
the data tell the story, an idea (theory) is not imposed upon the data. 

Comparison of the Model of Pharmacist Interceding with other pharmacy 
expectations research shows some agreement. For example, DeSimone, Peterson, and 
Carlstedt (1977) began their study with an idea that customers had some needs and an 
expectation that their pharmacist might meet those needs. However, their research 
focused on the number and types of questions posed by pharmacy customers, using 
pharmacists as the data recorders. Their focus on customers asking questions limited their 
findings and did not allow them to completely tap the customers' perceptions. In this 



98 
study, question asking is a way that customers may identify a need. Need identification 
(i.e., question asking) was found to be a component of the Model of Pharmacist 
Interceding, not an explanation for the expectations construct. 

Other pharmacy researchers have included the expectation construct in a studies of 
customer satisfaction. The advantage of this study is the focus on customer expectations, 
and the processes surrounding that construct. Results are not muddied by the intrusion of 
other constructs. 

Limitations 

The purposive sample for this study included twenty-seven community pharmacy 
customers. While data were collected until saturation, the proportion of independent 
pharmacy customers to chain pharmacy customers was a limitation of this study. Because 
the choice of type of pharmacy may indicate a difference in customer needs, a more 
diverse sample could strengthen and improve the Model. In addition, more women than 
men participated in the interviews. While women are the most frequent pharmacy 
customers, additional interviews of male pharmacy customers would strengthen the 
results. Finally, participants in the study came from all socio-economic backgrounds, but 
the addition of participants at the lower end of the education spectrum would be 
beneficial, as they may have additional and/or varied needs. 






99 
Recommendations for Pharmacy Practice 

When a customer enters a pharmacy, they are usually entering a world that they do 
not understand. As health care professionals, pharmacists have a duty to recognize and 
act on their customers needs. The Model of Pharmacist Interceding provides pharmacists 
with new insight into the needs created by the medication use system for their customers. 
The Model shows pharmacists that their customers expect them to intercede (i.e., act on 
their behalf) in a system that is complex and confusing. Finally it demonstrates that the 
consequence of pharmacist interceding, is the formation of a relationship between 
pharmacist and customer. Pharmacists may find that the Model is useful in assessing their 
practices. 

Recommendations for Future Research 

As health care professionals, pharmacists and those involved in pharmacy research 
have a responsibility to their customers. This responsibility includes both making sure that 
the customer has the right medicine at the right time, and interceding on behalf of that 
customer in our complicated medication use system. The ability to intercede on the 
customer's behalf will be enhanced by research aimed at further understanding the 
problems and processes that pharmacy customers face. 



100 
Recommendations for research taken from this study include: 

1 . Research designed to further expand the Model of Pharmacist Interceding. 
That is, specific research should be undertaken to expand and better 
understand each component of the Model. 

2. Research designed to develop processes that pharmacists may use to assess 
the needs of their customers. 

3. Research designed to develop interventions that will teach the pharmacist 
to recognize and act on their customers' needs. 

4. Research designed to develop an understanding of the relationships formed 
by pharmacist interceding. 

5. Research designed to develop qualitative evaluations of pharmacist 
interceding. 

6. Research designed to develop methods to educate customers in the specific 
way(s) that their pharmacist(s) may intercede, so that the customer may (1) 
clearly articulate their needs and (2) better understand their rights in the 
medication uses system. 



In closing, the Model of Pharmacist Interceding, as presented in this research, 
illustrates a substantive theory of customer expectations of community pharmacy services. 
The Model not only explains those customer expectations (i.e., that their pharmacist will 
intercede) but also provides descriptions of the processes that lead to and from those 
expectations. The usefulness of the Model may be found in this thick description and 
analysis that creates a clearer theoretical understanding of customer expectations of 
community pharmacy services. 



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APPENDIX A 
INITIAL INTERVIEW GUIDE 



1. Please think about your last visit to a pharmacy to pick up a prescription. You 
arrived at the pharmacy and opened the door. What happened next? What did the 
pharmacy look like? Where were the people? Who were the people? What were 
you doing? What were they doing? What was said? When was it said? What was 
the most important thing that happened during your visit? 

2. When you need a prescription, what are your minimum expectations of a 
pharmacy? What about the facilities? Services? Personnel? 

3. Now imagine the ideal pharmacy visit in your eyes. Please describe an ideal visit 
to that pharmacy. How is it different than the minimum you described a minute 
ago? Facilities? Services? Personnel? 

4. Please think about a pharmacy visit when your expectations were not met. What 
happened? What was different? Who was involved? Facilities? Services? 
Personnel? 

5. Are there any times when your expectations might be different? 

6. Have you ever had a change in your health plan that necessitated a change in 
pharmacies? How did you choose the new pharmacy? What were your 
expectations for service in that new store? Facilities? Services? Personnel? 

7. Suppose you move to a new town. How do you choose a new pharmacy? Why? 

8. Suppose someone asked you for a recommendation. Describe the pharmacy that 
you would recommend. Facilities? Services? Personnel? 

9. Do you currently patronize one pharmacy? More? Why? 









106 



APPENDIX B 
REVISED INTERVIEW GUIDE 



1 . Please think about your last visit to a pharmacy to pick up a prescription. You 
arrived at the pharmacy and opened the door. What happened next? What did the 
pharmacy look like? Where were the people? Who were the people? What were 
you doing? What were they doing? What was said? When was it said? What was 
the most important thing that happened during your visit? What was missing in 
regards to the people, facilities, pharmacist? 

2. What should happen when you visit your pharmacy? Why? (Facilities, People, 
Services) 

3. What should NOT happen when you visit a pharmacy? Why? (Facilities, People, 
Services) 

4. Please think about a pharmacy visit when things did not go as you wished. What 
happened? What was different? Who was involved? Facilities? Services? 
Personnel? 

5. Now imagine the ideal pharmacy visit in your eyes. Please describe that ideal visit 
to the pharmacy. How is it different than a "usual" visit to the pharmacy? 
Facilities? Services? Personnel? 

6. Are there any times when your expectations might be different? For example a new 
vs refill prescription, chronic vs acute illness, or emergency vs not emergency visit. 

7. Think back to the first time you remember having a prescription filled. What 
happened? What was missing? What was the prescription for? A chronic vs acute 
illness? How did you feel? What is the most important thing that happened? 

8. Describe your experience as a pharmacy customer. Do you have an acute or 
chronic illness? How long since your diagnosis? How often do you visit a 
pharmacy? Do you shop at a chain, clinic, and/or independent pharmacy? 

9. How does having to take a prescription make you feel? 

107 



108 



10. What is the "worst" thing about having to take prescription medication. The best? 
How could it be better? 

11. What is the most important thing that your pharmacy can do for you? The least 
important? 

12. Have you ever had a change in your health plan that necessitated a change in 
pharmacies? How did you choose the new pharmacy? What were your 
expectations for service in that new store? Facilities? Services? Personnel? 

13. Suppose you move to a new town. How do you choose a new pharmacy? Why? 

14. Suppose someone asked you for a recommendation. Describe the pharmacy that 
you would recommend. Facilities? Services? Personnel? 

15. Do you currently patronize one pharmacy? More? Why? 

16. How would you describe yourself in regards to your illness? For example, are you 
proactive, passive, aggressive? 


















APPENDIX C 
DEMOGRAPHIC AND PHARMACY EXPERIENCE QUESTIONS 



In what month and year were you born? 
Occupation: 



Retired from that occupation? Yes No 



3. Highest grade of school or college that you have completed: 

4. Pharmacy Experience: 

Number of prescriptions per month: 

How often do you visit a pharmacy? 

Weekly Monthly Quarterly Yearly Other: 



How many years have you been purchasing prescriptions on own? 

Type of store patronized: Chain Independent Clinic Other 

Do you have a chronic illness? 

Type of chronic illness: 



How long since diagnosis? 



Onset of illness Sudden Gradual Other 

5. How do you categorize your health status? 

Poor Fair Good Excellent 

6. How do you pay for your prescriptions? Self Share Others 



109 



BIOGRAPHICAL SKETCH 

Born in Camp Lejeune, North Carolina, Barbara Brice lived in the South and on 
the island of Okinawa before her parents settled in Florida in 1972. She received a 
Bachelor of Arts degree in marketing from the University of South Florida in 1981, and a 
Master of Health Administration degree from the University of North Florida in 1993. 
Since 1984 Barbara has co-owned and managed the Medicine Shoppe Pharmacy in 
Jacksonville, Florida, with her husband Lee, a Gator Pharmacist. Together they are 
raising two children, Kate and Rob. Barbara will earn her Doctor of Philosophy degree 
from the University of Florida in May 2000, and plans to pursue a career in research and 
teaching. 



110 



I certify that I have read this study and that in my opinion it conforms to 
acceptable standards of scholarly presentation and is fully adequate, in scope and quality, 
as a dissertation for the degree of Doctor of Philosophy. 




Earlene Lipowsktf Chair 
Associate Professor of Pharmacy 
Health Care Administration 



I certify that I have read this study and that in my opinion it conforms to 
acceptable standards of scholarly presentation and is fully adequate, in scope and quality, 
as a dissertation for the degree of Doctor of Philosophy. 



Carole Kimberlin 

Professor of Pharmacy Health Care 
Administration 



I certify that I have read this study and that in my opinion it conforms to 
acceptable standards of scholarly presentation and is fully adequate, in scope and quality, 
as a dissertation for the degree of Doctor of Philosophy. 





Richard Segal 
Professor of Pha/macy Health Care 
Administration 



I certify that I have read this study and that in my opinion it conforms to 
acceptable standards of scholarly presentation and is fully adequate, in scope and quality, 
as a dissertation for the degree of Doctor of Philosophy. 




Sally Hutchinson 



Professor of Nursing 



This dissertation was submitted to the Graduate Faculty of the College of 
Pharmacy and to the Graduate School and was accepted as partial fulfilment of the 
requirements for the degree of Doctor of Philosophy. / / / A - /)//,//], 



May 2000 




f /V* * Kp f TV*^- 

''Dean, College of Pharmacy 



Dean, Graduate School 












UNIVERSITY OF FLORIDA 



3 1262 08555 2759